Prasad Chappidi, M.D., Neurologist and Headache Specialist


Patient Information Sheet


Name of Patient ___________________ Age _____ Date of Birth _______

Married ( ) Single ( ) Divorced ( ) Widowed ( ) Home phone ____________________

Address ____________________ Social Security _______________________

City ___________________ Zip Code ______________ Sex Male ( ) Female ( )

Occupation ____________________ Referring Doctor ______________________

Employer _____________________ Employer's Address ____________________

Employer's Address ___________________________________________________

Cell Phone (For emergency contact/appointment reminders) ______________________

Nearest friend or relative for emergency ______________________________

Phone ______________________


Insurance Information

Primary Insurance

Insured name _______________________ Group Name ______________________

ID __________________________

Secondary Insurance

Insured name _______________________ Group Name ______________________

ID __________________________

I hereby authorize Dr. Prasad Chappidi to release to my insurance company any information acquired in the course of my examination or treatment . I hereby authorize benefits to be paid directly to him. I understand I am responsible for any unpaid balance.

Signed ___________________________________ Date ____________________



Center for Neurological Disorders

Prasad Chappidi, M.D.

Office Locations

Professional Building of Community First Medical Center
5600 West Addison
Suite 406
Chicago, IL 60634
Tel: 773.205.9800
Fax: 773.205.9801
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Resurrection Professional Building
7447 West Talcott, Suite 523
Chicago, IL 60631
Tel: 773.775.2323
Fax: 773.775.2343
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