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Office Forms
Do you like being prepared for your appointments?
Feel free to fill out these forms online, print and bring them with you to your scheduled appointment.
You can also fax them ahead of time to (818) 342-3937
or you can email them to Ingrid at Welcome@fyeye.com
Please be sure to bring you current glasses or if you are having a contact lens exam, please wear your current contacts & bring the prescription information to your scheduled exam.
Patient Forms
Patient Information Form |
This form needs to be filled out yearly or if you are new to our office. Please also fill out this form if you have recently changed address or phone number. |
Patient Health History Form |
This form is an overal view of your health. This is where you list the problems you are having, what diagnosis you have had, what medication you are taking and what surgeries you have had. |
Eye Glass (Refraction) Form |
This is the form that needs to be signed acknowledging the fee associated with checking for glasses. If you have a seperate vision insurance (VSP or Optum Health) then your annual eye exam covers this test. If you are a returning eye glass wearer to Dr. Zdenek then you may be eligible for a discount. Please ask a staff member if the discount applies to you. |
Contact Lens Form |
If you choose to wear contact lenses then there may be an additional fee for the contact lens exam/fitting. If you are a returning contact lens patient with Dr. Zdenek, then you may be eligible for a discount. Please ask a staff member if the discount applies to you. |
Payment Policy Form |
This form explains our office expectations on payment and how you would receive a bill from our office. |
Misc. Office Forms
Release of Medical Records to Dr. Zdenek Form |
This form needs to be filled out and mailed or faxed to your previous doctor in order for our office to obtain your records from your previous doctor's office. |
Release of Medical Records from Dr. Zdenek Form |
This form needs to be filled out if you would like a copy of your medical record. Fees may apply. |
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