Patient Forms
| Welcome to our Office |
For patients who have never been seen at our office, this form asks for basic information such as name and address, eye related symptoms, personal medical history, medications, allergies, and family medical history.
Primary Insured member is the person whose name the insurance is under. If you have concerns about disclosing your SSN, most insurances only require the last 4 digits. Check with a staff member when you are here for your appointment.
Generally, when you make your appointment we have already gathered the necessary information to verify your insurance eligibility and benefits.
Primary Insured member is the person whose name the insurance is under. If you have concerns about disclosing your SSN, most insurances only require the last 4 digits. Check with a staff member when you are here for your appointment.
Generally, when you make your appointment we have already gathered the necessary information to verify your insurance eligibility and benefits.
| Update - Personal & Medical History |
This is for returning patients who have not completed a new history form in over 3 years, even if all the information is the same. If any information has changed (address, phone number, personal and family medical history, medications, allergies) please document. It is one of the HIPAA requirements. Thank you for understanding.
Primary Insured member is the person whose name the insurance is under. If you have concerns about disclosing your SSN, most insurances only require the last 4 digits. Check with a staff member when you are here for your appointment.
Generally, when you make your appointment we have already gathered the necessary information to verify your insurance eligibility and benefits.
Primary Insured member is the person whose name the insurance is under. If you have concerns about disclosing your SSN, most insurances only require the last 4 digits. Check with a staff member when you are here for your appointment.
Generally, when you make your appointment we have already gathered the necessary information to verify your insurance eligibility and benefits.
| pt_wellness_screening.pdf |
Please complete COVID-19 screening form and bring to your appointment.
Proposition 65
WARNING: Eyeglass frames and lenses can expose you to chemicals including nickel, which is known to the State of California to cause cancer, and Bisphenol-A, which is known to the State of California to cause birth defects or other reproductive harm.
For more information go to: www.p65warnings.ca.gov
For more information go to: www.p65warnings.ca.gov
