Chesterfield Ophthalmology

Forms

All Patients - New and Current

Blue eyes tend to be more sensitive to light.

Blue eyes tend to be more sensitive to light.

The Method To Our Madness...

Although it seems like a pointless and irrelevant task, there is constructive reasoning behind our request for your medication list. Thorough and accurate documentation of your medication and health history information improves the efficiency and quality of your overall care, and helps avoid potential treatment risks.  In addition to preventing prescription errors, your individual medication and medical history consideration is useful in detecting possible drug-related pathology or changes in clinical signs that may be the result of drug therapy or systemic disease processes.

A good medication history should encompass all current and recently prescribed drugs (brand or generic name, dosage, route and frequency taken), any previous adverse drug reactions including hypersensitivity reactions, any over-the counter medications, including herbal or alternative medicines, and adherence to recommended therapy.

 

Please download, complete and print forms 1 - 5.

  1. Patient Information
  2. Patient Medical History Record
  3. Financial Policy Acknowledgment
  4. Refraction Policy Acknowledgment
  5. HIPAA
  6. Notice of Privacy Policy
    (This form is for your information. There is no need to bring this page to our office.
  • It is very important to bring to your appointment a complete list of all current medications, both prescription and over the counter. Include exact dosage instruction and method of use (oral, nasal, drop). Thank you - this information assists us with your treatment and care.
  • Please be aware it is the patient's responsibility to check with your insurance company to see if a referral is needed and to obtain it prior to your appointment.
  • We look forward to seeing you soon!