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Davis Duehr Dean Eye Care - Patient Forms
Please download, print and fill out the form(s) below only if you have been requested to do so by a Davis Duehr Dean ophthalmologist, optometrist or their staff.
Bring the completed form(s) with you to your
clinic visit. These forms are in PDF format. You will need Adobe
Acrobat Reader 
to
view these forms.
Patient Registration Form 
This form is to be completed by patients who are coming in for the first time
for an eye exam.
Patient Questionnaire
This form provides your eye doctor with an overview of your health history
and eye concerns. This questionnaire should be completed and brought to
your
first eye appointment.
Insurance Authorization
This form is used to verify your insurance coverage. We need this form completed
and signed in order to file a claim to your insurer.
Permission for Verbal Communications
This form allows a patient to identify and give permission for other individuals
(family members, etc.) to discuss your health information and treatment without
you being present.
Learn more about Permission for Verbal Communications
Notice of Privacy Practices
If you are a new patient, when you check in at the registration desk, you will
be asked to review and sign a Notice of Privacy Practices form. It is helpful
to read our health information privacy
protection policy (PDF) prior to
your clinic visit.
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