Forms

In order to make your next visit with us as efficient as possible, please take a moment before your scheduled appointment to print and complete the following patient forms:

• Notice of Privacy Practices and Notice of Privacy Practices Acknowledgement – Please read carefully and complete and sign the acknowledgement where requested.
• Medical History Questionnaire – The information requested in this form better allows our physicians to care for you, and must be completed by all new patients, and established patients who have not been seen in the last 3 years.
• Notices and Fees – Please read carefully, initial applicable lines and sign at the bottom.
• Financial Policy – Please read carefully and initial applicable lines.

Other Forms and Appointment Information 

• Authorization to Disclose Medical Records: Continuity of Care Release Form  (If applicable) – In some cases, Oregon Eye Specialists may need other providers to share pertinent medical information with us which requires your authorization. Please fill out if this situation applies to you.
• Authorization to Disclose Medical Records (If applicable) – In some cases, Oregon Eye Specialists may need to share pertinent medical information with referring providers which requires your authorization. Please fill out if this situation applies to you.
• Authorization to Examine Minors (If applicable) – 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 applicable) – 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.
• 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.

If you prefer, we also welcome you to complete these forms in our office by arriving 10-15 minutes early to your next scheduled appointment.

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