Forms

Dear New Patient,

We would like to take a moment to personally welcome you to our practice. We are pleased that you have chosen Advanced Eye Care and Glaucoma Center for your Eye Care. It is our responsibility to deliver the best care possible to you. We are a full spectrum ophthalmology practice specializing in the care of patients of all ages with subspecialty in glaucoma.

Our office hours are Monday – Friday 9:00am - 5:00pm, with the office being closed for lunch from 12:00-1:00 pm. You may reach us at 949-777-5970. In order to make your first visit more effective please complete the 4 enclosed forms. Please mail them to us prior to your appointment or bring it to our office at your appointment.

1.   Registration Form #1
2.  Health Questionnaire /Medical history #2
3.  Consent to obtain electronic medication history #3
4.  Medical Record Release Authorization Form #4

We appreciate if you come 15 minutes before your appointment. When you arrive for your first appointment, please bring the following with you:

1.  All of your health insurance cards (we will ask for them at every visit).
2.  Any type of vision service plans insurances which covers eye glasses or contact lens services
3.  Photo identification
4.  All medications list, including vitamins and over the counter medications
5.  Pharmacy information

Please call our office if you have any questions or need to reschedule your first appointment. We do require 24-hour notice if you are unable to keep a scheduled appointment.

Information transmitted by email or via our website may be viewed by others, and we cannot guarantee the privacy of any information transmitted in this way.

Thank you for choosing Advanced Eye Care and Glaucoma Center for your Eye Care.

Sincerely,
Dr. Ghiasi and Staff

#1 Patient regestration
#2 Medical History
#3 Consent to Obtain Electroinc Medication Information Form
#4 Medical Record Release Authorization Form
Notice of Privacy Act
Payment Policies and Insurance Plan Benefits (for patient information)
Patient Referral Form ( for refering offices)