Do you like to be prepared?

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 Michele at

Please be sure to bring your current glasses to your exam. If you would like to update your contact lens prescription, you will need a seperate Contact Lens Exam (can be done at the same time as your Annual Eye Exam). Please wear your current contacts to your exam and bring your prescription information to your scheduled exam (your contact lens boxes will sufice)

New Patient Forms for Dr. Zdenek's office Print forms

If you are new to our office or haven't been in to see Dr. Zdenek with in the past year then you will need to fill out the following forms.


Patient Information 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 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) 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 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.
Tear Function Survey This form helps explain to Dr. Zdenek how your eyeballs feel. Being a Dry Eye Specialist, Dr. Zdenek has linked Dry Eyes to several conditions, including poor sleep. He has found that treating his patients Dry Eyes (which they didn't think they had) led to better sleep!
Payment Policy This form explains our office expectations on payment and how you would receive a bill from our office.