New Patient Form

In Case of Emergency, Contact Person

How Did You Hear About Us?

Medical Health History


Release Of Information

I assign all medical/surgical benefits to Robbins Eye Associates for services performed by Robbins Eye Associates staff and authorize the release of information concerning my care to the health insurance agency. I understand and agree that, regardless of insurance status, I am ultimately responsible for the balances of my account for any professional services rendered. Furthermore, I understand that if my account is turned over for collection, I will be responsible for all fees and expenses incurred by any collection agency or attorney.

(Patient/Guardian/Responsible Individual – must be 18 years or older to sign)