Patient Forms


Patient History and Privacy Form

Please print these forms and complete before your appointment. The first two pages are the patient history forms used by all our patients to list their name, address, insurance information, medical and eye care history, medicines used, etc. The third page is a required HIPPA (Notice of Privacy Practices) form to be signed after reading the privacy notice either in our office or on the bottom of this web site's home page. Thanks for helping us more efficiently serve you at our office.

Insurance Assignment and Release Form

Use this form to authorize Medical, Vision, and/ or Medicare benefits to Drs. Buckingham or Kaminski for services/ goods furnished to me.

Record Release Form

Use this form to have another office release your records to our office or to have your records released from our office to another provider/ entity.