Patient Forms Download Page
NEW PATIENTS: It is important that you fill the forms out accurately and completely. There are many factors that could affect the health of your eyes. Please avoid the temptation of thinking some of the requested information is not pertinent or important.
RETURNING PATIENTS: If your contact, insurance, or medical condition has changed since your last visit please resubmit the form.
The form consist of four pages. They are:
PAGE ONE: PATIENT CONTACT INFORMATION
PAGE TWO: EYE HEALTH & VISION HISTORY
PAGE THREE: PATIENT MEDICAL HISTORY
PAGE FOUR: PATIENT MEDICAL HISTORY (part 2)
To download click on the form's image below.
All four pages will appear in your download folder or directly in your browser.
Print the form making sure you have all four pages.
Fill out ALL the information and bring the completed form with you to your appointment.
For privacy and security reasons we do not use on-line transfer of your medical and personal information.
Eye Care for Kids
Darek Huggett, OD & Associates
1469 Capitol Street NE, Suite 100
Salem, Oregon 97301, USA
Call for an Appointment
Save time by filling out the
prior to your appointment.
To download: CLICK HERE
IMPORTANT IF YOU ARE USING INSURANCE
When scheduling your appointment please provide:
• Insurance company name
• Insurance I.D. number
• Group number if applicable
• Primary insurance holder name and date of birth
(if different than the person being scheduled)
Monday – Thursday 9:30am - 5:30pm
Friday: 9:30am - 5:00pm
Saturday 10:00am - 2:00pm