Sarasota Vision, Cataract, Lasik, Cosmetic Facial Surgery, Skin Care Center in Sarasota, Bradenton and Venice, FL

Patient Forms

Overview

Ask Amy

Testimonials

New Patient Registration Forms

Surgery Information

Payment Options & Financing Plans

Surgery Center

Transportation

Make Payment Online

For your convenience, new patient forms are available to you online. This may save you time by completing the forms prior to your arrival for your scheduled appointment.

General Forms

Patient History (PDF - 77KB)
Please fill out this form and bring it with you on your initial appointment. Thank you.

Patient Registration Packet (PDF - 220KB)
Complete patient form packet

Notice of Privacy Practices (PDF - 33KB)
Please print out this form and retain it for your records. Thank you.

Patient Acknowledge of Receipt of Privacy Practices and Authorization to Release Information (PDF - 19KB)
Patient Acknowledgement of Receipt of Notice of Privacy Practices and Authorization to Release Protected Health Information

Financial Agreement and Lifetime Signature Authorization (PDF - 27KB)
Please fill out this form and bring it with you to your appointment. Thank you.

Medical Release Form (PDF - 38KB)
Request to release medical records

Vision Plans versus Medical Insurance - Explanation of Coverage (PDF - 21KB)
This form explains the differences between vision plans and medical insurance. Please bring the completed form to your upcoming appointment.

List of Current Medications (PDF - 17KB)
Please fill out and bring this completed form to your upcoming appointment.

Routine Eye Care

Lifestyle Questionnaire (PDF - 33KB)
Please fill out this form and bring it with you to your appointment. Thank you.