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Forms

Pediatric Medical History Form for new patients – PDF

After reading the HIPAA privacy statement we ask that you print this acknowledgment out and sign it. When you arrive for your initial appointment, please bring a signed copy to the office . By law, we must keep it on file as a part of your medical record.

HIPAA Privacy Acknowledgment – PDF

This is our privacy policy. Please review it before your first appointment.

HIPAA Privacy policy – PDF

This form would be used if you would like us to transfer your records to another doctors office.

Medical Records Release Form – PDF

Download this PDF to view the full warranty information we give out with every pair of glasses we sell.