VisionSource! - North America's Premier Network of Private Practice Optometrists
North America's Premier Network of Private Practice Optometrists

Patient Information Forms

 


Help us make your appointment time with us go more smoothly.
Please print and complete the appropriate forms before your appointment. Bring the completed forms with you to your appointment. This will save time when you are here and allow us to proceed more smoothly. If you have any questions, feel free to call us or arrive early for your appointment and ask us at that time.

 

Forms included in this section:

  1. Privacy Policy for Dr. Ira Tucker and Associates
  2. Acknowledgement of Receipt of Privacy Policy
  3. Patient History Questionnaire
  4. Medical Records Release—To us
  5. Medical Records Release—From us
  6. Optomap Screening Form

All new patients:

 

  1. Privacy Policy
  2. Acknowledgment of Receipt of Privacy Policy
  3. Patient History Questionnaire (please print, complete and bring with you to appointment)
  4. Optomap Screening Form

 

All eye exam appointments—new and returning patients

 

  1. Privacy Policy
  2. Acknowledgement of Receipt of Privacy Policy
  3. Patient History Questionnaire unless you know that you have completed one in the past. This is a relatively new form. Thus most returning patient will need to complete on at this time. Please print, complete and bring this form with you to your appointment
  4. Optomap/GDxVCC Screening Form

 

To request that we send your prescription or other information to another doctor:
Please print the form “Medical Records Release—from us” and complete it carefully. Be sure to give us address and fax information for the person to whom you wish to have us send the information. Please sign, provide your birthdate and include a contact phone number for yourself in case we have any questions about this request.

 

Please send the completed form to us by mail, fax, or email. Or you may bring it to our office.

 

                                                    Mailing address:   Dr. Ira Tucker and Associates
                                                                                 570 New Waverly Place, Suite 110

                                                                                 Cary, NC 27518

                            

                                                    Fax:  919-858-8455

 

                                                    Email: Please call our office for email address (919-858-7555)

 

Requests for release of medical information will be processed within 2 business days from receipt of the request whenever possible.

 

To request that another provider send us information about you:
Contact the other provider’s office to determine what their procedure is for sending us your medical records or prescription. If you need to send them a medical records release form, you may use one provided by the other provider or print the form “Medical Records Release—to us” and send it to your previous provider.