Patient Forms

Do You Like To Be Prepared?

Feel free to fill out these forms online and email them or you can print them 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 our office

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 separate 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 suffice)

New Patient Forms For Dr. Zdenek’s Office

If you are new to our office or haven’t been in to see Dr. Zdenek within 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 overall 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 separate vision insurance (VSP or Optum Health) then your annual eye exam covers this test. If you are a returning eyeglass 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 patient’s 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.

If you’re unable to open these files, you probably need to download the free Adobe Reader program, click here to download or click on the Adobe Reader icon

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Monday: 8am - 5pm
Tuesday: 8am - 5pm
Wednesday: 12pm - 6:30pm
Thursday: 8am - 5pm
Friday: 8am - 5pm
Closed Weekends

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