"Where we care for you like family"
  • Home
  • About Us
    • Reviews
  • Services
    • Contacts
    • Medical Care Management
    • Comprehensive Vision Examinations
  • Optical Shoppe
  • Forms
  • Insurance
    • Financing
  • Contact Us
  • FAQ
  • Blog
  • Image Gallery

New Patient Forms
Please print out and bring with you to your upcoming examination

Patient Intake Form
File Size: 1684 kb
File Type: pdf
Download File

Our practice's patient intake form is intended for those patients that are being seen at our practice for the first time.  The form consists of questions related to reason for visit, the patient's medical history and lifestyle as well as family medical history.
HIPAA FORM
File Size: 37 kb
File Type: pdf
Download File

Our practice's HIPAA form is purposed for the protection of every patient's medical records and other personal health records. It sets boundaries on the use and release of medical records.    
FINANCIAL AGREEMENT
File Size: 36 kb
File Type: pdf
Download File

Our practice's financial agreement states our office policies and procedures for co-payments, deductibles and any monetary responsibilities of our patients regarding services and products rendered.
RELEASE OF RECORDS
File Size: 85 kb
File Type: pdf
Download File

 The records release form is a written authorization that allows the patient and/or someone other than the patient to obtain a patient's medical records and additional information.
Home
About Us
Services
Optical Shoppe
​Forms
Insurance​
Contact Us

Family Eye Care

​​1871 S. Randall Rd., Ste A
Geneva, IL 60134

Phone: (630) 377-2020
   Fax:  (630) 402-0527
eyedocsmail@gmail.com
Hours
  • Home
  • About Us
    • Reviews
  • Services
    • Contacts
    • Medical Care Management
    • Comprehensive Vision Examinations
  • Optical Shoppe
  • Forms
  • Insurance
    • Financing
  • Contact Us
  • FAQ
  • Blog
  • Image Gallery