Our Documents section contains common forms used in our office. Please feel free to print the forms you need prior to your visit and bring them to your appointment. Please call the main reception number (454-7400) if you should have any question concerning any forms contained on this page.
General Patient Information
It has been my honor and privilege to be your physician for many years in Bloomington/Normal. I will continue to care for patients and conduct office visits at this location until August 2, 2020. On August 3, 2020 I will retire from private practice and begin a new group practice at The Woman’s Center at Sara Bush Lincoln Hospital in Mattoon, Illinois. I have enjoyed my time here immensely, but am looking forward to spending more time with my family. My colleague and neighbor in suite 360, Dr. Nona Fulk, will become the custodian of my records after that date. You may wish to seek a referral from your health plan or health department for a new physician. You may also schedule appointments with Dr. Fulk’s office as they will have your records.
In the event you would like records transferred to another physician, please fill out a record request form available at the front desk and on our website. You may request your own records with the same form. Records will require two weeks to prepare and must be picked up in person by you with identification. No records will be mailed. Finally, you may request records from Dr. Fulk’s office after August 2, 2020. No records will be available from this office after August 2 and no care will be available at this office.
Again, thank you. I appreciate all the relationships developed over the years and will miss seeing all of you. I would be delighted to see anyone who will be in the Mattoon area and would like to become a patient at Sara Bush.
Please stay healthy and be well.
Dr. Jeffrey Galvan