At AssureVision, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.
- You will need AdobeReader® to download and complete the forms. Click here to download.
- Download the required form(s). Print out the form(s) and complete the required information.
- Fax your printed and completed form(s) to our office or bring them with you to your appointment.
New Patient Health History Form – Required
Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals your have regarding your eye health or vision on the form.
ARLINGTON TOWN SQUARE
58 S. Arlington Heights Rd
Arlington Heights, IL 60005
Phone: (847) 368-9999
BARRINGTON VILLAGE CENTER
143 W. Main Street
Barrington, IL 60010
Phone: (224) 407-2020