Northern Virginia Eye Doctor

NORTHERN VIRGINIA OPHTHALMOLOGY ASSOCIATES, P.C.

Your Vision is Our Focus

COVID-19 Protocols: Please click here to learn about our current COVID-19 safety protocols.

Patients Visiting the Fairfax Office: Please enter the office through the main lobby. For assistance locating the main lobby entrances, please click here.

PATIENT HUB

FORMS

Attention: Please do not use the duplex, or double-sided, printing option when printing forms from our website. Instead, please print one form per sheet of paper to ensure proper scanning of your forms on your appointment date.

Additionally, on the date of your appointment, you may be asked by our staff to complete and sign our Billing Forms, including our Check-In Form and/or one of our waivers. Thank you.

POLICIES

Notice of Privacy Practices

Updated February 2014

GENERAL PATIENT FORMS

For patients seeing our adult ophthalmologists or our optometrists.

New Patient Packet

Medical History Update Form

Meaningful Use Demographics Form

HIPAA Consent Form

e-Prescribing Consent Form

Insurance Waiver Form

Medical Records Release Form

Text and Email Authorization Form

QUICK LINKS

ADDITIONAL RESOURCES

American Academy of Ophthalmology (AAO) Eye Smart (English)

American Academy of Ophthalmology (AAO) Eye Smart (Spanish)

American Association of Pediatric Ophthalmology and Strabismus (AAPOS) Patient Information (Mutiple Languages)

PEDIATRIC & STRABISMUS FORMS

For patients seeing Dr. Diora, Dr. Ellis, Dr. Jeffery, Dr. Morrison, or Dr. Seidman only

New Patient Packet

Medical History Update Form

Meaningful Use Demographics Form

HIPAA Consent Form

e-Prescribing Consent Form

Insurance Waiver Form

Medical Records Release Form

Text and Email Authorization Form

Minor Consent Form

You will need Adobe Reader to access our Forms. To download this program, click here.

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