Patient Forms

At Eye Surgeons Associates, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.

To minimize your wait time, you may pre-register with our office by filling out our secure online registration form as this enables us to quickly update your record during your visit. After you have completed the form, please review your information and press the Submit button to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it. (Note: When the form has been submitted correctly you will receive a message which contains a confirmation number. Please make note of this number.)

If you are unable to complete our online process, please print the forms below, complete and bring with you to your appointment.

  • You will need AdobeReader® to download and complete the forms.
  • Download the required form(s). Print out the form(s) and complete the required information.
  • Fax your printed and completed form(s) to our office or bring them with you to your appointment.

Patient Registration

Download & Print Form

Medical History Questionnaire

Download & Print Form

Consent for Medical Treatment, Release of Information

Download & Print Form

Acknowledgement of Receipt of Notice of Privacy Practices

Download & Print Form

Financial Policy

Download & Print Form


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Contact Us

We look forward to hearing from you

Locations

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Office Hours

Our Regular Hours

Monroe

Monday:

8:00 am-5:00 pm

Tuesday:

8:00 am-5:00 pm

Wednesday:

8:00 am-6:00 pm

Thursday:

8:00 am-5:00 pm

Friday:

8:00 am-5:00 pm

Saturday:

Closed

Sunday:

Closed

Canton

Monday:

8:30 am-5:00 pm

Tuesday:

8:30 am-5:00 pm

Wednesday:

8:30 am-5:00 pm

Thursday:

8:30 am-5:00 pm

Friday:

8:30 am-5:00 pm

Saturday:

We are open the 2nd and 4th Saturday from 8a to 12p

Sunday:

Closed