.
Forms are available on this page.
Please print and complete all forms BEFORE appointment.
Please be sure to bring your medical insurance card at the visit.
We do NOT submit to any vision plans.
*NOTICE FOR HMO PATIENTS*
If you have an HMO insurance, please be aware that it is YOUR RESPONSIBILITY as an HMO patient to confirm your eligibility (in-network) and the status of your REFERRAL, with your
Primary Care Physician (PCP)
If you DO NOT have a referral for the
date of service, you will be responsible for
payment.
For the safety of our patients and staff:
**Please follow our protocols and guidelines**
Notify us if you and/or your child has experienced:
-cold or flu-like symptoms
-cough/sore throat
-fever in the last 24hrs
-vomiting/nausea
**THESE 5 FORMS ARE REQUIRED FOR YOUR INITIAL VISIT **
Printable PDF FORMS (non-fillable)
1. New Patient Intake
2. New Patient General Medical History
3. Office Policy 2021
4. Authorization Form for Parent/Legal Guardian
5. Notice of Privacy Practices
**PLEASE BE SURE TO CHECK IF YOU HAVE PRINTED CORRECTLY TO ENSURE NOTHING HAS BEEN CUT OFF**
Patient(s) are required to be accompanied by a Parent/Legal Guardian at the first visit.
**PLEASE BE ADVISED, FOR A PATIENT'S FIRST VISIT, THE PATIENT WILL BE GETTING A FULL COMPREHENSIVE EXAM, INCLUDING DILATION. PLEASE PLAN TO BE HERE FOR 1 TO 1 1/2 HOUR(S).
**WE DO NOT MAKE APPOINTMENTS OR DO CONSULTATIONS VIA EMAIL**
PLEASE CALL THE OFFICE (847) 256-2020
Miscellaneous Forms (THIS IS NOT REQUIRED FOR NEW PATIENTS):
Release of Records from Pediatric Eye Associates
Forms are available on this page.
Please print and complete all forms BEFORE appointment.
Please be sure to bring your medical insurance card at the visit.
We do NOT submit to any vision plans.
*NOTICE FOR HMO PATIENTS*
If you have an HMO insurance, please be aware that it is YOUR RESPONSIBILITY as an HMO patient to confirm your eligibility (in-network) and the status of your REFERRAL, with your
Primary Care Physician (PCP)
If you DO NOT have a referral for the
date of service, you will be responsible for
payment.
For the safety of our patients and staff:
**Please follow our protocols and guidelines**
Notify us if you and/or your child has experienced:
-cold or flu-like symptoms
-cough/sore throat
-fever in the last 24hrs
-vomiting/nausea
**THESE 5 FORMS ARE REQUIRED FOR YOUR INITIAL VISIT **
Printable PDF FORMS (non-fillable)
1. New Patient Intake
2. New Patient General Medical History
3. Office Policy 2021
4. Authorization Form for Parent/Legal Guardian
5. Notice of Privacy Practices
**PLEASE BE SURE TO CHECK IF YOU HAVE PRINTED CORRECTLY TO ENSURE NOTHING HAS BEEN CUT OFF**
Patient(s) are required to be accompanied by a Parent/Legal Guardian at the first visit.
**PLEASE BE ADVISED, FOR A PATIENT'S FIRST VISIT, THE PATIENT WILL BE GETTING A FULL COMPREHENSIVE EXAM, INCLUDING DILATION. PLEASE PLAN TO BE HERE FOR 1 TO 1 1/2 HOUR(S).
**WE DO NOT MAKE APPOINTMENTS OR DO CONSULTATIONS VIA EMAIL**
PLEASE CALL THE OFFICE (847) 256-2020
Miscellaneous Forms (THIS IS NOT REQUIRED FOR NEW PATIENTS):
Release of Records from Pediatric Eye Associates