Patient Forms

For your convenience, some of our most common patient documents are available online. If you prefer to complete a hard copy, please contact us at 800-282-9905 and we’ll be happy to send what’s needed via U.S. mail.

Cataract Patients

Patient Information

Medical History

Authorization for Release of Patient Information – Individual – (Family member, spouse, friend)

Authorization for Release of Protected Health Information (PHI) – Medical facility – (Doctor, Hospital, Clinic)

Patient Statement of Rights and Responsibilities

Notification Regarding Patient Rights

Surgery Center Patient Information Card & Map

Lifestyle-Questionnaire

Hearing-Services-Questionnaire

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New and Existing Patients

Patient Information

Medical History

Authorization for Release of Patient Information – Individual – (Family member, spouse, friend)

Authorization for Release of Protected Health Information (PHI) – Medical facility – (Doctor, Hospital, Clinic)

Hearing-Services-Questionnaire

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Lasik / Refractive Patients

Patient Information

Medical History

Authorization for Release of Patient Information Individual – (Family member, spouse, friend)

Authorization for Release of Protected Health Information (PHI) – Medical facility – (Doctor, Hospital, Clinic)

Refractive Evaluation Health History

Lifestyle-Questionnaire

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Hearing Services Patients

Hearing Services New Patient Form

Hearing Services Questionnaire

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St. Luke’s at The Villages Patients

Patient-Information-St.-Lukes-At-The-Villages

Medical History – St. Luke’s at The Villages

Authorization for Release of Patient Information – Individual – St. Luke’s at The Villages

Authorization for Release of Patient Information -Medical Facility – St. Luke’s at The Villages

Patient Statement of Rights and Responsibilities – St. Luke’s at The Villages

Notification Regarding Patient Rights – St. Luke’s at The Villages