Online Patient Forms

Patient information

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Billing information

If yes, please provide the billing address information below

General Eye History

General Medical History

Review Of Systems

Please list any problems you are currently having anywhere, from head to toe:





HIPAA Privacy Policy, Preferred Method of Contact, Financial Agreement and Consent to Treatment: Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View Patient Financial Policy

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ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

The law requires that Bedford Vision & Eye Clinic, PLLC make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:



I have read or had explained to me, prior to any services offered, Bedford Vision & Eye Clinic, PLLC's Notice of Privacy Practice and agree to continue my care with Bedford Vision & Eye Clinic, PLLC under said terms.



I was given the opportunity to read Bedford Vision & Eye Clinic, PLLC's Notice of Privacy Practices and declined, but wish to continue my care with Bedford Vision & Eye Clinic, PLLC under the terms of Bedford Vision & Eye Clinic, PLLC's privacy policies.



I have read or had explained to me, prior to any services offered, Bedford Vision & Eye Clinic, PLLC's Notice of Privacy Practice and do not wish to continue my care with Bedford Vision & Eye Clinic, PLLC under said terms.



The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reasons described as



I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.



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* By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I accept has the same validity and meaning as my handwritten signature.