Darek Huggett, OD & Associates

Darek Huggett, OD & Associates

PATIENT FORMS DOWNLOAD PAGE

 

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.

CLICK HERE OR ON IMAGE BELOW TO DOWNLOAD FOUR-PAGE PATIENT FORM

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Patient Medical History Forms

Call to make an appointment

Darek Huggett, OD & Associates

1469 Capitol Street NE, Suite 100

Salem, Oregon 97301, USA

IMPORTANT IF YOU ARE USING INSURANCE:

When scheduling your appointment please provide:

• Insurance Co. • Insurance I.D. #  • Group #

• Primary Insurance Holder Name & Date of Birth

SAVE TIME BY FILLING OUT THE

PATIENT MEDICAL HISTORY FORMS

PRIOR TO YOUR APPOINTMENT.

Business Hours

Monday – Thursday 9:30am - 5:30pm

Friday: 9:30am - 5:00pm

Saturday 10:00am - 2:00pm

Sunday Closed

 

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