Los Gatos Eye Care
  • Home
  • OUR TEAM
    • Team of Staff
    • Ilene Polhemus, OD
    • Briana Broussard, OD
    • Maggie Enciso, OD
  • Services
  • CONTACT LENSES
  • Optical
  • Forms
  • Hours & Location
  • Contact us
    • Schedule an Appointment
    • Patient Satisfaction Survey
  • Eye Education
  • Reviews

Welcome to Los Gatos Eye Care

Below are our patient forms. You may choose to print and fill them out prior to your initial appointment. 
You will need Adobe Acrobat Reader to view these files.
​

What to bring to your exam:

  • Current insurance cards/information
  • Current glasses
    • ​Primary glasses
    • Sunglasses / Sports glasses
    • Computer glasses
  • Contact Lens Patients:
    • Wear contact lenses to the appointment (Insert at least 2 hours prior)
      • DO NOT wear contact lenses if you are having SEVERE problems, but please bring them in your contact lens case
    • Contact Lens Prescription or boxes, labels, vials with specifications on it
    • Name of contact lens solutions

Financial Policy

Patient Financial Policy and Expectationsss
File Size: 74 kb
File Type: docx
Download File

Financial policy signature

Patient financial policy signature
File Size: 69 kb
File Type: docx
Download File

Authorization to retain credit card information

Authorization to retain credit card information
File Size: 81 kb
File Type: doc
Download File

Patient history form ADULT

Patient History Form Adult
File Size: 66 kb
File Type: docx
Download File

Medical history form for children under 16 years old

Patient Medical History Form - Pediatric
File Size: 49 kb
File Type: docx
Download File

Records release authorization form (to LGEC)

Records release authorization form (to LGEC)
File Size: 83 kb
File Type: doc
Download File

Records release authorization form (from LGEC)

Records release authorization form (from LGEC)
File Size: 85 kb
File Type: doc
Download File

  • Home
  • OUR TEAM
    • Team of Staff
    • Ilene Polhemus, OD
    • Briana Broussard, OD
    • Maggie Enciso, OD
  • Services
  • CONTACT LENSES
  • Optical
  • Forms
  • Hours & Location
  • Contact us
    • Schedule an Appointment
    • Patient Satisfaction Survey
  • Eye Education
  • Reviews