*Required fields are marked with an asterisk.
Below you will find the forms for your appointment. If you are new to our practice, all forms will need to be filed out prior to your appointment.
Please read the Welcome Letter as it provides information to prepare for your appointment. The forms can be downloaded and printed for your convenience.
PLEASE BE AWARE OUR OFFICE DOES NOT BILL VISION PLANS, ONLY MEDICAL PLANS.
Vision plans provide coverage for routine exams, glasses, and contact lenses. If you have trouble with your vison (nearsighted, farsighted, astigmatism, etc.), your visit is considered a vision problem and would be covered by your vision
plan. Many insurances will not cover your visit if there is no medical diagnosis.
If your NEW PATIENT APPOINTMENT is scheduled in 2019
Please fill out the 2019 patient paperwork below.
2019 ADULT PAPERWORK:
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.
Please note the Notice of Privacy Practices Acknowledgment is only a summary of our Privacy Practices.
Medical Records Release
Use this form to have your records sent to David A. Ewing-Chow, MD, PLLC from another physician or medical practice. This form may be used to have your records with David A. Ewing-Chow, MD, PLLC sent to another physician or practice in the event
you are relocating or wish to transfer to another physician.