patient forms  <a href="/gloucester/">Gloucester</a>

At West Point Vision Care, 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.

  • 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 at 804-843-9031 or bring them with you to your appointment.

New Patient Health History Form – Required

Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals your have regarding your eye health or vision on the form.

Download & Print Form

HIPAA Privacy Authorization Form

This form is for patients to indicate individuals like friends or family members with whom they are giving permission for us to discuss or disclose their protected health information to.

Download & Print Form

Patient Responsibility Statement Form – Required

This form outlines the patient’s financial responsibility for payments for services and products rendered, regardless of whether or not they have insurance.

Download & Print Form

Records Release Request Form

This form is for patients to use if they have another provider that they need us to obtain medical service records from. By completing this form, it gives us permission to request the information from the other provider and for the other provider to release this information to us.

Download & Print Form

West Point Vision Care Return Policy – Required

This form explains in detail our policies for returns or refunds on all products and services offered at West Point Vision Care.

Download & Print Form

Notice of Privacy Practices

This is a copy of our Privacy Practices Policy. You may download and print a copy for your records. Individual copies are not available on site.

Download & Print Form

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