Patient Forms

You need Adobe Reader to read these files.
Click the link below to get Adobe Reader for free.
(if you don't already have it)
Adobe Reader

Patient Registration and History Forms for Buffalo Grove Eye Care Center

Please print out this form (2 pages), fill it out, and bring the form into Buffalo Grove Eye Care Center.

Patient Registration Form (PDF)


Patient Registration and History Forms for Libertyville Vision Center

Please print out this form (2 pages), fill it out, and bring the form into Libertyville Vision Center

Patient Registration Form (PDF)


HIPAA Form and Acknowledgment

Please read the HIPAA Page, then print and sign the HIPAA Acknowledgment, then bring the acknowledgment in with you.

HIPAA Page (PDF)
HIPAA Acknowledgment (PDF)

Thank you for filling these forms out in advance.

From The Staff