Notice of Data Incident
Related Pages

In order to make your next visit with us as efficient as possible, please take a moment before your scheduled appointment to print, read carefully, complete and sign where requested our patient intake forms:

For your convenience, our Privacy Practices Notice is available online (above) to read before your next visit. If you are unable to do so before arriving, hard copies are also available in our clinic.

Other Forms and Appointment Information | Please fill out the form is the situation applied to you. 

  • Authorization to Disclose Medical Records: Continuity of Care Release Form – In some cases, we may need other providers to share pertinent medical information with us which requires your authorization.
  • Authorization to Disclose Medical Records  – In some cases, we may need to share pertinent medical information with referring providers which requires your authorization.
  • Authorization to Examine Minors  – Unless a court has stated otherwise (and a formal legal document can be provided to us), the parents listed on the birth certificate are the only people allowed to approve medical care being provided to a child. If a parent or LEGAL guardian is not bringing the child to his/her appointment, then we need permission from the parent that we can see that child. Please complete the information to authorize us to see your child with the following people you would like to be able to bring your child to appointments.
  • Vision Quality Questionnaire  – If you are patient who is scheduled for surgery or YAG laser procedures,  please fill out the Vision Quality Questionnaire and bring it along to your appointment.
  • Vision Quality Questionnaire Spanish Version
  • Why Does Oregon Eye Specialists Ask For My SSN and ID? – Every time you come in for an appointment our clinics will need to appropriately identify you, as will many insurance companies we may bill on your behalf. Please read this form carefully for a detailed explanation on why we request specific identification.
Forms

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