Premier Retina Specialists​

10100 Loop 40 W, Midland, TX 79706  

432-617-0181

For Life-Threatening Emergencies Call 911

 

We are located down the street from Midland International Air and Space Port,

next door (west) to the Post Office.

Patient Forms

 

Save time on your first visit by getting some paperwork out of the way ahead of time. Download and print out the forms below.
Then, fill in the blanks and bring them with you to your first appointment

 

Please be advised that by using these forms, we are not confirming an appointment nor establishing a physician-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into these forms. Online communication is not intended for acute, emergency, or life-threatening health conditions. If you believe you are having a health emergency, contact 911 or go to your nearest emergency department.

Patient Registration Form

Download by clicking here.

 

Patient History Sheet

Download by clicking here.

 

Family History Sheet

Download by clicking here.

 

Permission to Release Health Information

Download by clicking here.

 

Medical Records Release Form

Download by clicking here.

.

Notice of Privacy Practices

Download by clicking here.

 

 

You might need the Adobe Reader to use these files.
If you need to download it, click here.

 Patient Registration Form                                Download by clicking here.

 

 

Patient Medical History Sheet                          Download by clicking here.

 

Patient Medications                                           Download by clicking here                               

 

Family History Sheet                                         Download by clicking here.

 

 

Permission to Release Health Information      Download by clicking here.

 

 

Medical Records Release Form                         Download by clicking here.

 

.

Notice of Privacy Practices                                Download by clicking here.

 

 

You might need the Adobe Reader to use these files.
If you need to download it, click here.

Serving the Midland, Odessa, Pecos & San Angelo, TX Areas