To help the doctor and staff devote the most possible time to you and your vision care, please do the following:

    1. Please download, complete, and bring in the forms below 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.

 

NEW PATIENT FORMS
New Patient Form Welcome Form – Please take a few minutes to complete this form. This information is confidential and will not be released without your consent.
Child History Form Please take a few minutes to fill out this form. The information will make for better use of our appointment time. Also it will tell us what examination routines will best apply to your child’s problem. This information is confidential and will not be released without your consent.

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.
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.