Established Patient Forms

I accept responsibility for and guarantee payment for any fees charged for the patient’s treatment, regardless of any insurance benefits the patient is entitled to, and assign the benefits payable for physician services to the physician.

I have read the notice of Privacy Practices. If I request a copy of today’s consult report, unless I indicate otherwise, this will be sent via email. Also a reminder for any follow up appointments may be sent via email unless I indicate otherwise. I also consent to permitting use of the patient’s photograph for medical education programs and medical publications. I agree that Pediatric Ophthalmic Consultants may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payors for treatment purposes.

Thank you for completing these forms on line. Required fields will be highlighted if missed. Once your forms are complete and successfully submitted a confirmation page will appear and copies will be emailed to the address entered.