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Specialty Care

Call Us 630.743.4500

Midwestern University’s Multispecialty Clinic combines the best aspects of a traditional clinic with the strengths and advantages of a university affiliation. The Multispecialty Clinic offers a comprehensive, patient-centered healthcare experience at the Speech-Language Institute, the Physical Therapy Institute, and the Eye Institute. At the Speech-Language Institute, graduate speech-language students evaluate and treat a wide-range of speech disorders under the supervision of licensed speech pathologists. The Physical Therapy Institute provides comprehensive outpatient physical therapy and offers a variety of evidence-based treatments. Licensed clinical faculty evaluate each patient to determine their individual needs and goals and develop unique treatment plans designed to restore function back into the lives of patients.The Eye Institute’s licensed optometry faculty and students work together to ensure the highest quality eye care using the latest technology.The Eye Institute’s provides exceptional,comprehensive specialty and vision care services to their patients.

Specialty Care
Eye Institute
Physical Therapy Institute
Speech-Language Institute
Patient Information

Optometry & Ophthalmology Referral Form

IL - Eye Institute Optometry Referral Form

Referral Information

Referral Services (Please check all that apply) *

Pediatric Service & Binocular Vision

Ocular Prosthesis

Vision Therapy / Sports Vision

Electrodiagnostics

Specialty Contact Lens

Low Vision / Vision Rehabilitation

Dry Eye

Acquired / Traumatic Brain Injury

Lipiflow / IPL

OtherOther

Reason for Referral *

Consultation

Diagnostic Testing

Transfer of Care

Treatment / Therapy

Co-Management

OtherOther

Additional Information / Accommodations Needed

Upload Patient Records (If Applicable)

Maximum upload size: 1.54MB

Patient Information

Name *

Date of Birth *

Address *

Address

Street Address

Street Address

Address

City

City

State

State

Zip Code

Zip Code

Phone *

Insurance *

Referring Provider

Name *

Address *

Address

Street Address

Street Address

Address

City

City

State

State

Zip Code

Zip Code

Phone *

Fax

Authorization

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

If you are human, leave this field blank.

Sending

Healthcare Professionals Referral Form

IL - Eye Institute Healthcare Referral Form

Referral Information

Referral Services (Please check all that apply) *

Routine Eye Care

Pediatric / School Eye Exam

Contact Lens

Diabetic Eye Exam

Acquired / Traumatic Brain Injury

Ocular Prosthesis

Loss of Vision

Strabismus / Eye Turn

Dry Eye

Flashes / Floaters

Plaquenil Screening

Red Eye

Eye Pain / Eye Strain

Low Vision / Vision Rehabilitation

OtherOther

Additional Information / Accommodations Needed

Upload Patient Records (If Applicable)

Maximum upload size: 1.54MB

Patient Information

Name *

Date of Birth *

Address *

Address

Street Address

Street Address

Address

City

City

State

State

Zip Code

Zip Code

Phone *

Insurance *

Referring Provider

Name *

Specialty *

Address *

Address

Street Address

Street Address

Address

City

City

State

State

Zip Code

Zip Code

Phone *

Fax

Authorization

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

If you are human, leave this field blank.

Sending

Take A Closer Look

A Closer Look Video

Optical and Contact Lens Services

A Closer Look Video

Specialty Eye and Vision Services

A Closer Look Video

Eye Institute

A Closer Look Video

Speech Language Institute

A Closer Look Video

Physical Therapy Institute

Upcoming Events

Aphasia and Stroke Awareness Night

October 25, 2023

7:00pm - 9:00pm

Midwestern University Speech-Language Pathology Program

Specialty Clinic News

Physical Therapy

Movement Therapy at Midwestern University Clinics Assist Patients with Mobility

Dillon

Physical Therapy

Movement Therapy at Midwestern University Clinics Assist Patients with Mobility

Physical Therapy

The Midwestern University Physical Therapy Institute welcomes Colleen Krambeck, PT, DPT

Get To Know Our Health CareProfessionals

Health Care Professionals

Midwestern University Clinics Faculty Judith Ball

Judith Ball

M.S., CCC-SLP

Jane S Borgehammar

PT, MS

Audrey Bowlds

M.S., CCC-SLP

Fred Collison

O.D., FAAO

Jessica Conroy

O.D., FAAO

Midwestern University Clinics Faculty Christina Del Toro

Christina Del Toro

Ph.D., CCC-SLP

Midwestern University Clinics Faculty Daniel Deligio

Daniel Deligio

O.D., FAAO, FSLS

Midwestern University Clinics Faculty Thomas Dillon

Thomas Dillon

PT, DPT, OCS

Midwestern University Clinics Faculty Sarah El-Khazendar head shot news item

Sarah El-Khazendar

O.D., FAAO

Midwestern University Clinics Faculty Teri Elliott-Burke

Teri Elliott-Burke

PT, D.P.T., M.H.S.

Jenny Geevarghese

O.D.

Midwestern University Clinics Faculty John Gialousakis head shot news item

John Gialousakis

O.D., Ed.M, FAAO

Midwestern University Clinics Faculty Nicole Gilbert

Nicole Gilbert

M.A., CCC-SLP

Midwestern University Clinics Faculty Kimberly S. Hoffer

Kimberly S. Hoffer

M.A., CCC-SLP

Midwestern University Clinics Faculty RaMonda Horton

RaMonda Horton

Ph.D., CCC-SLP

Cindy Krizizke

M.S., CCC-SLP

Midwestern University Clinics Faculty Jenelle Mallios head shot news item

Jenelle Mallios

O.D., FAAO

Vakishan Nadarajah

O.D., FAAO, FSLS

Midwestern University Clinics Faculty Kathleen Post

Kathleen Post

M.S., CCC-SLP

Clinton Prestwich

O.D., FAAO

Midwestern University Clinics Faculty Janey Prodoehl

Janey Prodoehl

PT, Ph.D.

Quan, Adrienne

Adrienne C. Quan

O.D., FAAO

Balaji Rangarthnam

Balaji Rangarathnam

Ph.D., CCC-SLP

Midwestern University Clinics Faculty Samantha Rice

Samantha Rice

O.D., FAAO

Meredith Saletta Fitzgibbons

Ph.D., CCC-SLP

Smith, Matthew PTU

Matthew Smith

PT, DPT, MS

Midwestern University Clinics Faculty Melissa Suckow

Melissa Suckow

O.D., FAAO

Midwestern University Clinics Faculty Margaret Wilczek

Margaret Wilczek

O.D.

Midwestern University Clinics Faculty Jenna Williams head shot news item

Jenna Williams

O.D., FAAO

Midwestern University Clinics Faculty Jonathan Wilson

Jonathan Wilson

Ph.D., CCC-SLP

Midwestern University Clinics faculty Parres ?Wright

Parres Wright

O.D., FAAO

Midwestern University Clinics Faculty Hye Seon Yoo head shot news item

Hye Seon Yoo

O.D.

Illinois Clinics
Downers Grove Locations
3450 Lacey Road
Downers Grove, IL 60515
1.630.743.4500
Directions

Arizona Clinics
Glendale Locations
59th Ave & Utopia
Glendale, AZ 85308
1.623.537.6000
Directions

Arizona Clinics
Central Phoenix Location
2000 W. Bethany Home Rd.
Suite 200
Phoenix, AZ 85015
1.602.246.5525
Directions

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Dental Authorization Request

IL Dental - Release of Information

Patient Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Address *

Address

Address

Address

Address

Address

Address

Requested Information / Documents

Type of Documents *

Dental Records

Radiographic Images

Photographs

OtherOther

Dental Document Details

HIV / AIDS diagnosis, treatment or testing information

Behavioral Health Notes

Alcohol or drug abuse treatment information

Purpose *

Treatment

Financial

Personal

Insurance

Do Not Disclose Purpose

OtherOther

Authorization

This authorization will expire 1 year from 09/21/2023.

I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.

Alcohol and Drug Abuse Treatment.
To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.

HIV / AIDS Information
To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.

Behavioral Health Notes / Record
I authorize the disclosure of any behavioral health notes or information in my medical record.

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

Sending

Endodontic Referral

IL-Endodontic Referral Form

Referral Information

Referring Name Facility *

Referring Dentist *

Referring Dentist Email Address *

Facility Phone Number *

Patient Information

Patient Name *

Sex *

Female

Male

Other

Patient Date of Birth

Patient Mailing Address *

Patient Mailing Address

Street Address

Street Address

Patient Mailing Address

City

City

State

State

Zip Code

Zip Code

Patient Email Address *

Patient Phone Number *

Emergency Contact Name *

Emergency Contact Phone Number *

Comments

Authorization

Community Partner site to email this completed form to communitypartners@midwestern.edu. Midwestern will
contact the patient to schedule an appointment within 48 business hours of receipt.

Midwestern will reserve an appointment time for the patient. The length of time to complete your agreed upon
treatment depends on the individual needs of each patient. As a teaching facility, care will require longer
appointments than you may be accustomed to in a private dental office. Additionally, procedure completion may
require more than one appointment. Valid ID is required for patient registration.
Patient referral is valid for 30 days from date of referral on form and patient must be seen within those 30 days.
If patient is taking medications, please remind them to bring a list to their appointment.
Patient must be screened and accepted into the dental program prior to any treatment. For the no charge endodontic
Community Partner therapy program, the patient will be provided with a limited exam and radiograph.
Retreatments are not a covered benefit under the Community Partners endodontic therapy program.
Some complex cases may be determined to be a non‐teaching case and outside the scope of the program.
If patient does not require endodontic therapy, patient will be referred back to referring dentist for treatment.
If patient is provided with endodontic therapy, the patient understands that treatment will include a restoration [core] to
temporarily protect the tooth, at no charge to the Community Partner patient. Please note the tooth may still need additional
definitive treatment.
Patient understands that this referral is for potential limited treatment only for the listed tooth on the referral and the
patient may choose to return for comprehensive care at our clinic.
Patient must provide a current valid government issued photo ID.

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

If you are human, leave this field blank.

Sending