Patient Forms

Below are several forms that can be downloaded and printed.  We do not expect our patients to print and fill them out before arriving at our office, but doing so would greatly expedite your visit with us.

In general, all patients coming in for an eye examination will need to fill out the Refraction Charge form, Medical History Questionnaire, and  Financial Agreement.  New patients and returning patients who have not visited since March 1, 2010, will also need to fill out the Patient Information Form and Privacy Acknowledgement Form.  Records Release Forms only need to be printed out if you are requesting a release of your medical records.

Form Specific Information

Patient Information Form: If you have been to our office since March 1, 2010, you do not need to fill this out.  All other patients, including returning patients who have not visited since March 1, 2010, must fill this form out at the office or bring in a completed form. Please remember to sign and date the second page.

Financial Agreement Form: Every patient must fill this form out at least once a year.

Privacy Acknowledgement Form: Every new patient must fill this form out.  Returning patients only need to complete this form if they have not done so before.  Before signing this form, please read our Privacy Practices.

Refraction Charge Form: Every patient coming for a comprehensive exam must fill this form out, unless you are using a vision plan.  Bear in mind that prescribing glasses is not a medically necessary procedure, and therefore will not be covered by most major medical insurances when performed during a medical examination.

Medical Questionnaire: A full medical history is required not only by insurance companies, but also by the doctor, in order to best treat you.  We ask that you complete one of these forms if you are a new patient, or are coming in for your regular eye exam.

Records Release Form: This form authorizes our office to acquire records from another practitioner or to send your records to other practitioners.