New Patient Forms

Office Phone: 757-436-0011

Welcome to Hampton Roads Retina Center! We look forward to providing you with care.website 035

Please bring the following items with you to your first appointment:

1. Please print and fill out all three forms at the bottom of this page.

2. Bring your insurance card(s) with a photo ID to your scheduled appointment. If your insurance
requires an authorization or referral, please ensure that it is completed prior to your visit.

3. Bring a list of current medications and dosages (prescription or over-the-counter) to your scheduled appointment.
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Please be aware that your appointment could take at least two hours. You may consider bringing a driver, since your eyes will be dilated when you leave.

Payments of any copays, deductibles, and/or coinsurance will be due at the time of service.

If you have any questions prior to your visit, please contact our front office at 757-436-0011.

Thank you!


Forms

1. New Patient Packet

2. Authorization To Release Information

3. Medical History Questionnaire