New Patient Registration Form

Disclosure of Information

Patient Medical History

Consent for Procedures

AVASTIN Information and Consent

LUCENTIS Information and Consent

EYLEA Information and Consent

– These PDF-format forms can be downloaded to your computer, then viewed and printed as an Adobe Acrobat file. Each form is just one page and should download quickly onto your computer.

– Please print the forms above and fill them out and consider faxing them to our office at (413) 746-9715. This way, any questions our staff might have can be sure to be resolved before you arrive for your first appointment.

– If you prefer, you can bring your completed forms to your first appointment or fill them in once you arrive for your appointment. If you plan to fill in your forms at the office, we recommend that you arrive 15 minutes early to your appointment.

About your office visit:

• Your eyes will be dilated for the examination.
• You will need someone to drive you.
• Your visit may last between 1 and 3 hours depending on the type of evaluation.
• Diabetic patients are asked to bring a snack in case the appointment runs into their lunch or dinner time.

Please bring the following with you on the day of your appointment:

• The completed registration forms
• A list of all medications and eye drops that you are currently taking
• Any contact lenses or glasses that you currently wear
• Your current insurance cards
• Co-pays for specialists as noted on your insurance card
• Referrals from your primary care physician if your insurance requires a referral to see a specialist.
• A valid picture identification card

NOTE: If Medicare is your only insurance, a co-payment will be collected at the time of the office visit. If we do not participate with your insurance, payment will be collected at the time of the office visit.