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Patient Forms

New Patients

If you are a new Terry Reilly patient please fill out a registration form and bring it with you to your first visit.

Patient Registration Form

Dental Health History

ROI Form

Delegation of Authority to Make Health Care Decisions

General Consent/Financial Responsibility

Covid Vaccine Patient Form

COVID-19 Vaccine Screening

Patient Information

Colonoscopy Miralax Split-Dose Prep

Colonoscopy 2 Day Prep

Colonoscopy Instructions Using SUPREP Bowel Kit

 Upper Endoscopy Preparation Instructions 

Allumbaugh House

Allumbaugh House

Visitation Information

New Patient Orientation

Screening Assessment Form

Notice of Privacy Practices

This notice explains how your medical and other health information about you may be used and disclosed. It also outlines how you can access your information. If you have any questions about this notice please contact our Privacy Officer, at (208) 466 – 7869 Ex. 1273.

Notice of Privacy Practices

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Missed Appointment Policy as of March 1, 2022

New patients who fail to keep an appointment three times in a row (75% of your medical/dental appointments) will be placed on “Same Day Only” scheduling status. This means your appointments can no longer be scheduled in advance, but based on availability the same day you call. This policy helps us better serve our community, our patients and their families while also allowing our medical team to be prepared as possible for all health visits. We understand that life circumstances occur and you occasionally need to cancel an appointment. We kindly ask that you give us 24 hour notice for this.


There are several ways to cancel an appointment:

  • reply to the text message or reminder calls with the “cancellation” option

  • manage your appointment through the MyChart app

  • call our clinics to reschedule your appointment

 

We appreciate having you as a patient and appreciate your regard in this matter.

Medicare Shared Savings Program
Terry Reilly Health Services is an Affordable Care Organization

This notice explains the program and how it benefits patients. 

Medicare Shared Savings Program

TRHS Vaccine Policy Statement

Terry Reilly Health Services supports childhood immunizations. They are a vital part of safeguarding the health of your children. Staying up-to-date on your child’s vaccines not only helps protect your child, it also helps protect others in your community—like a friend who cannot get certain vaccines, or a neighbor’s new baby who is too young to be fully vaccinated. When everyone eligible for vaccines takes part, we are better protected against the spread of disease in the community.
While we encourage childhood immunizations, we also recognize and respect a parent’s right to make choices regarding your child’s healthcare. Our providers are here to provide information and answer questions so you can make the decision that’s right for your family. Our pharmacists and providers welcome your questions regarding immunizations.


Terry Reilly offers a schedule of recommended immunizations based upon age. Information statements about all the vaccines offered at Terry Reilly Health Services are here: https://www.immunize.org/vis/

How To File a Safety Concern with The Joint Commission

Terry Reilly Health Services is accredited by The Joint Commission. The Gold Seal of Approval® is a symbol of quality reflecting our commitment to provide safe and effective care.

To report a patient safety event:
Office of Quality and Patient Safety
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181

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