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DPNS Physician Appointment Forms

Please print and complete the following forms. Bring the completed forms, your insurance card, and photo identification to your appointment.




The insured individual's date of birth and social security number are required. Please let us know if you do not wish to provide your social security number. The date of birth of the insured cannot be excluded. We require this information in order to file claims in a timely manner.

Cancelation Notice

We kindly request a 24-hour notice for cancellations. Same day cancellations and/or missed appointment fees are $50-$100 and based on the length of the appointment. Please call our office at (847) 272-4433 if you would like to cancel or change your appointment.

Insurance Network

DPNS is in-network with the following list of provider networks.

  • 1st Health

  • Aetna

  • BCBS

  • BCBS HMO – Site 447 Only (Northshore)

  • Cigna

  • HFN

  • Humana

  • Medicare

  • PHCS

  • Unicare

  • United Healthcare

Please note we have seen an increase in policies that limit members to a narrower network of providers. We highly recommend you contact your insurance company to verify that DPNS is in-network with your specific coverage prior to scheduling. When speaking with your insurance company, keep in mind that our office is not affiliated with NorthShore University Health Systems.

Our office does not participate with any medical assistance policies such as Medicaid plans. In addition, all HMOs policies except Northshore BCBS Precision HMO will require a referral from your primary care physician.

Prescription Refills

To request a prescription refill, please contact your pharmacy and ask for a refill request to be faxed to (847) 272-4434 or sent electronically.

For products purchased in our office, please call (847) 272-4433.

Center for Aesthetics Appointment Form

Center for Aesthetics Cancellation Notice
For most appointments, we kindly request a 24-hour cancellation notice. Same day cancellations and/or missed appointment fees are $100. Please know that HALO and CoolSculpting appointments require a non-refundable $500 deposit and a 72-hour cancellation notice.

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