Buffalo Grove

(847) 459-6060

Barrington

(847) 382-4116

Buffalo Grove

(847) 459-6060

Barrington

(847) 382-4116



Patient Forms

Patient Forms

PATIENT INFORMATION

Document detailing basic information regarding the patient and medical history.

HIPPA FORM

Document detailing Doctor/Patient Confidentiality

HIPPA PRIVACY

Document detailing the Privacy Policy of Premier Eye Care and Surgery

RECORDS RELEASE

Document authorizing the release of Records

COMMUNICATION FORM

Provides information on who we are allowed to communicate with

SCHOOL EYE EXAM

Form to fill out for eye exams required by schools

Pediatric Consent

Consent by proxy for nonurgent pediatric care