Office Forms

If possible, please download (“save”) the following forms, and complete the Health History Form & Authorization for Information Release, and bring the completed forms with you at the time of your appointment. Alternatively, you may FAX them to us at 425-377-8757 at any time prior to your appointment.

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Please identify any medical condition(s) which you or your close relatives may have. Please make an X for any body system in which you have had or currently have a diagnosed disease &/or symptoms…

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I authorize my optometric physicians professional office named above to release health information identifying me (including, if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services) under the following terms and conditions…

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It is completely my decision whether or not to agree to this authorization to release my information as described in the Notice of Privacy Practices which was offered for my inspection.  While I cannot be refused treatment if I choose not to agree to this authorization…