Patient Paper Forms
It is more convenient to complete Patient Foms Online. If you prefer to complete paper forms, use Fom #1 and Form #2.
Paper Forms You Can Print and Complete Later
- If you are a New Patient to Dr. Dugas complete Forms #1 and #2.
- If you are a Former Patient and have not seen Dr. Dugas at the 1000 W. 39th St.office or have had a change in address or personal information, complete Form #1.
This form provides our clinic with demographic and insurance information that we're required to keep on file in your medical record. It also includes an Authorization to Release Information and an Acknowledgement that you have read the Notice of Privacy Pollicies.
Other Forms and Information
Notice of Privacy Policies (on website)
The Federal Health Information Portability and Accountability Act of 1996 (HIPAA) requires that our clinic inform you of how we use, disclose and maintain the privacy of all the information we collect about you as our patient. We ask that you read this document.
This form is to be used if you would like your past provider to release your medical and/or prescription information to our doctor, or in the event that you would like our doctor to release your medical record and/or prescription information to another provider. If this is your first visit to our clinic and you have had an eye exam within the past three years, we ask that you complete this form.
Laser Eye Surgery
Instructions regarding laser surgery and what to expect. What to do before and after the procedure.