Below you will find several forms that you may need to facilitate your care with Retina Specialists. Please be aware that this may not be a complete list of all required forms. If you have any questions about which forms may be needed, or if you require assistance while answering questions, please contact our office.

Patient Registration Form

This form gives us your basic information so that we can create your patient profile.

Registration Form (English)
Registration Form (Spanish)

Please bring with you on your first visit and DO NOT fax or e-mail.

Medical History Form

This form gives us your detailed medical history. Please be as thorough as possible so that we can provide the best and most timely care when you arrive at our office.

Medical History Form (English)
Medical History Form (Spanish)

Please bring with you on your first visit and DO NOT fax or e-mail.

HIPAA Consent Form

This form gives us your permission to collect and use your protected health information (PHI) during the course of your treatment. It also outlines any limitations you may place on the use and/or dissemination of this information.

HIPAA Form

Please bring with you on your first visit and DO NOT fax or e-mail.

Medical Records Release Authorization

This form gives us your permission to collect your medical records from and/or share your medical records with, one of your other medical providers.

Medical Records Release

Please bring with you on your first visit and DO NOT fax or e-mail.

Notice of Information Practices

This form contains all of our current information practices related to the collection, use, and sharing of your Protected Health Information (PHI) during the course of your care with our practice.

Notice of Info Practices

First Time Visit Information and Map

First time patient? Download this form to ensure that you have all of the necessary documentation with you at the time of your first visit. This also includes a helpful map that will ensure your prompt arrival to our practice.

First Time Visit Info & Map (English)
First Time Visit Info & Map (Spanish)

PDF Viewers

NOTE: All forms require a PDF viewer in order to be properly opened.