Forms



Note:

To help the doctor and staff devote the most possible time to you and your vision care, please download, complete, and bring all requested forms to us at your appointment or send them to us in advance to:
    6800 North 79th Street, Suite 101
    Longmont, Colordo 80503
or fax: 303 652-0606

Please bring appropriate information from other healthcare practitioners.

Even though the address reads Longmont, we are actually in the quaint little town of Niwot which is between Longmont and Boulder just off of CO 119 (Diagonal Highway). We are located in the South West corner of Cottonwood Square, just South of the intersection of Niwot Road and 79th Street.
see detailed directions here

Please let us know if your child has special needs such as delayed speech, poor motor control, or is confined to a wheel chair. We can do modified exams but need time set up the exam room, or we may need to schedule a longer exam.




HIPPA - Health Insurance Portability and Accountability Act
Notice of Privacy Practices This NOTICE OF PRIVACY PRACTICES ("NOTICE") describes how we use or disclose your health information and how we can get access to such information. PLEASE READ IT CAREFULLY.
Acknowledgement of Receipt of our Privacy Policy This form is required in all healthcare offices and acknowledges that you have access to, or have received a copy of the above NOTICE, and that our office will not release your records or any personal information without your written consent.


Authorization to Release Medical Information If you choose to have a doctor or staff from our office communicate with any person outside of this office, that person outside of our office must be noted on a separate signed form. The form has options for a limited time release, or open-ended (until revoked).
Permission To Disclose Personal Medical Information Please provide us with the telephone number you would like us to use when contacting you with regard to medical records, such as test results, treatment options, etc.


Child History Form This information is used by the doctor to better understand the child, the birth history, developmental milestones, school performance and specific problem areas of concern.


New Patient Information Form - Welcome to our Office Basic contact, health and visual needs information for use by the doctor and staff during your visit.


Information for Traumatic Head Injury Clients For TBI clients, especially those who have had an auto or vehicle accident, please fill in information as appropriate.