Name: Ridgeview Optometry
Address: 8540 Scarborough Dr, Ste 240, Colorado Springs, CO, 80920, US
Telephone: 719-495-5904
Price range: $000 - $300

Appointment Check-In
Name
First Last
Phone
Email
Date
MM slash DD slash YYYY
Appointment time

: Hours

Minutes

Your Primary Care Physician

In order to provide continuity of care, we ask that you provide us with your Primary Care Physician’s (PCP) information for your records.
Your PCP
Their Phone

Acknowledgement Of Receipt

I acknowledge that I received a copy of Dr. Dr. Matt Buchanan O.D., Notice of Privacy Practices (Your Information, Your Rights, Our Responsibilities - HIPAA).
Print Patient Name
Date
MM slash DD slash YYYY
Signature

Optomap Requirement
Consent
I understand that RidgeView Optometry performs the Optomap Retinal Imaging on all patients for $39 during all Annual / Comprehensive Eye Exams. This ensures you receive the best quality of care. If I cannot afford the $39 or have any questions or concerns, I will inform RidgeView Optometry staff.

Treatment Consent Form

I, (the patient), consent to receive treatment from Ridgeview Optometry.

Patient Name

Patient/Guardian Signature

Eye Emergency

Intake Form

Step 1 of 5 - Step 1

Appointment Check-In

Your Primary Care Physician

Acknowledgement Of Receipt

Optomap Requirement

Treatment Consent Form

Ridgeview Optometry