Patient Forms

Preparing for your first office visit is easy.
Please download all of the forms below and fill them out in the comfort of your home to save time in the waiting room.

New Patient Introduction to Practice

New Patient Information

Authorization For a Minor

Records Release Form

Patient Bill of Rights

New Patient Medical History

Surgery Questionnaire

If you are scheduled for a Dry Eye Appointment please fill out the following form.

Dry Eye Questionnaire

IPL Questionnaire and Procedure Information

Cataract Surgery Information

Below you will find information regarding your Cataract Surgery. Please review all sections prior to surgery. Thank you!

Preparing for Cataract Surgery

Entire Cataract Package Received During Your Cataract Pre-Evaluation

View/Download “Entire Cataract Package”

Overview of Cataract Packages and Prices

Please view/download the information regarding cataract packages and prices below.

Cataract Packages and Pricing

Informed Consent for Cataract Surgery (Must be completed for surgery)

The informed consent will need to be completed and brought with you when you meet with your surgeon. Fill out the Informed Consent for Cataract Surgery online here.

For a copy of the entire consent form, including the surgeon portion, click HERE.

Patient Portal Information

You will receive an email with login instructions for the Patient Portal. If you do not receive an email, please contact us. After activating your Patient Portal account on a web browser, you can use the mobile app, APPatient. Download the app below:

ABN (Must be completed prior to surgery)

View/Download ABN Form

Pre & Post Operative Cataract Surgery Information

Your family of Eyesight staff is here to assist you with every
aspect of caring for your eyes. Contact information below.

Insurance information

NOTE:  Although we participate with a number of medical insurance plans, there are several vision plans we do not participate with. Please check with your medical or vision plan provider for coverage. If you have questions, please contact our scheduling department at 603-436-1773.

CareCredit Healthcare Credit Card for Better Vision

There is an easier way to pay for your vision care including cataracts, oculoplastics, glaucoma, and contact lenses or glasses.  Eyesight Ophthalmic Services is pleased to accept the CareCredit credit card, North America’s leading patient healthcare financing program. CareCredit lets you begin your procedure or purchase your eyecare immediately — then pay for it over time with monthly payments that fit easily into your monthly budget. Whether you’re considering cataract surgery, oculoplastic surgery, or it’s simply time for new glasses or contacts, CareCredit can help you see clearer, sooner.

Attention contact lens patients:  Significant savings are available when purchasing 6 month or 1 year worth of contact lenses.  Consider applying for Care Credit and spread your payments out over a 6 or 12 month period – with no interest!  Contact our contact lens specialist to learn more!

Your Healthcare Credit Card

CareCredit is the credit card exclusively designed for healthcare services. CareCredit offers special financing on purchase of $200 or more* for healthcare procedures not commonly covered by insurance, including LASIK and Premium-IOLs. Why put off improving your vision tomorrow, when you can see clearer today?

*Subject to credit approval. Minimum monthly payments required. Visit www.carecredit.com for details.