Patient Forms  Download Page

EXPLANATION

 

NEW PATIENTS: It is important that you fill the forms out accurately and completely. There are many factors that could affect the health of your eyes. Please avoid the temptation of thinking some of the requested information is not pertinent or important.

 

RETURNING PATIENTS: If your contact, insurance, or medical condition has changed since your last visit please resubmit the form.

 

INSTRUCTIONS

The form consist of four pages. They are:

 

PAGE ONE:  PATIENT CONTACT INFORMATION

 

PAGE TWO:  EYE HEALTH & VISION HISTORY

 

PAGE THREE:  PATIENT MEDICAL HISTORY

 

PAGE FOUR:  PATIENT MEDICAL HISTORY (part 2)

 

 

To download click on the form's image below.

All four pages will appear in your download folder or directly in your browser.

 

Print the form making sure you have all four pages.

 

Fill out ALL the information and bring the completed form with you to your appointment.

 

For privacy and security reasons we do not use on-line transfer of your medical and personal information.

Eye Care for Kids

Darek Huggett, OD & Associates

1469 Capitol Street NE, Suite 100

Salem, Oregon 97301, USA

(503) 391-9570

1000's of Designer Frames

Eye Care for Kids

Call for an Appointment

(503) 391-9570

Hablamos Español

Save time by filling out the

PATIENT FORMS

prior to your appointment.

To download: CLICK HERE

IMPORTANT IF YOU ARE USING INSURANCE

When scheduling your appointment please provide:

  • Insurance company name

   • Insurance I.D. number

   • Group number if applicable

   • Primary insurance holder name and date of birth

     (if different than the person being scheduled)

Business Hours

Monday – Thursday 9:30am - 5:30pm

Friday: 9:30am - 5:00pm

Saturday 10:00am - 2:00pm

Sunday Closed

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