Los gatos EyeCare
  • Home
  • OUR TEAM
    • Team of Staff
    • Ilene Polhemus, OD
    • Barbora Bell, OD
  • Services
  • CONTACT LENSES
    • Routine Contact Lenses
  • Optical
  • Forms
  • Hours & Location
  • 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_form_2019.docx
File Size: 69 kb
File Type: docx
Download File

authorization to retain credit card information

authorization_to_retain_credit_card_information_2019.doc
File Size: 81 kb
File Type: doc
Download File

medical history form for ADULT patients

patient_history_form_-_adult.docx
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)

release_to_lgec.doc
File Size: 83 kb
File Type: doc
Download File

Records release authorization form (from lgec)

release__from_lgec.doc
File Size: 85 kb
File Type: doc
Download File

Proudly powered by Weebly
  • Home
  • OUR TEAM
    • Team of Staff
    • Ilene Polhemus, OD
    • Barbora Bell, OD
  • Services
  • CONTACT LENSES
    • Routine Contact Lenses
  • Optical
  • Forms
  • Hours & Location
  • Eye Education
  • Reviews