Patient Forms | Verdier Eye Center

Please note: Starting November 11, Dr. Siebert & Dr. Fox’s patients will be in suite 150 for appointments. Please utilize Door A or Door E, to access 150.

New Patient Forms

Prior to your appointment, please download and complete these forms:

New Patient Registration Form Medical History HIPAA Consent and Disclosure

If you cannot complete forms prior to your appointment, please arrive 5-10 minutes before your scheduled appointment to complete these forms in our office.

You may submit your completed form by:

Email: [email protected]

Fax: 616-949-8620

Bring the completed form to your appointment

Records Release Form

To request your medical records (Protected Health Information) be sent to another doctor, medical practice, or to receive a copy for yourself, please download this form:

Records Release Form

You may submit your Records Release Form by:

Email: [email protected]

Fax: 616-949-8620