Roosevelt Vision
Office Forms

Download Forms

Prior to your visit to our office, please fill out the appropriate forms below (click on icons to download). All forms are in Microsoft Word & PDF formats.

Please contact us if you have any questions.

Patient Registration Form
Every patient must fill out this form. Please fill out the top two thirds of the first page.

PDF Registration PDF

Contact Lens Exam
This form is only applicable to those patients who wear contacts now, and are scheduled for a 'Comprehensive Eye Exam with a Contact Lens Evaluation'. In addition to the Comprehensive Eye Exam form above, please fill out the top half of the page.

PDF ContactLensExam PDF

Notice Of Privacy Practices
Please keep the first two pages for your records, and to sign the third page and bring it to your appointment.

PDF PrivacyPractices PDF

Optomap ABN Form
Please fill out this form if we request authorization for consent to use Optomap.

PDF Optomap PDF



Eyewear Collection
Ask our team to help you pick the right frames for you.



>> View Entire Collection


Contact Lenses
Optix

Take a look at our variety of contact lenses that you can now reorder online!

>> Purchase Contact Lenses