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  Forms & Policies

These forms are intended to allow Valley Ambulatory Surgery Center to provide health care services to as many patients as possible in a timely manner. Please download the form, fill it out, and mail it back to VASC at the following address.

Valley Ambulatory Surgery Center
Patient Representative
2210 Dean Street
St. Charles, IL  60175

Forms & Policies Download:
You can download the Adobe Reader program free by clicking here.

Adobe PDF Insurance Information for Patients
Adobe PDF Patient History Form
Adobe PDF
Insurance Verification Form
Adobe PDF Special Patient Information/Patient Rights
Adobe PDF Informacion Especial Al Paciente – Derechos Del Paciente
Adobe PDF Pediatric Version of History Form
Adobe PDF Interventional Pain Clinic Form

  Valley Medical InnValley Ambulatory Interventional Pain ClinicLearn more about LAP-BAND® System Procedure
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