Please print and fill out the forms prior to your first visit.   

  • Form 1:   New patient information, insurance information, and medical history
  • Form 2:  Authorization for release of patient health information.  Please fill out the form completely.

Vision Specialist Report.  
Authorization form for release of this examination to the Secretary of State, Driver Services Department, Springfield, IL, for confidential use on my driving record.  This report is valid for six (6) months from the examination date.


State of Illinois Eye Examination Report.
Illinois law requires that proof of an eye examination be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for the other children.  The examination must be completed within one year prior to the first day of the school year the child enters the Illinois school system for the first time.