The Virginia Retina Center
Patient Forms
To help you prepare for your upcoming appointment, we’ve made our patient forms available online. You can download, complete, and bring these forms with you to save time at check-in. If you have any questions about the forms or which ones you need to complete, feel free to call our office, and we’ll be happy to assist you.
New Patient Registration Packet
Includes patient information, medical history, insurance details, and consent forms.
Download New Patient Registration PDF
Medical Records Release Form
Use this form to authorize Virginia Retina Center to release or request your medical records.
Download Medical Records Release PDF
Dilation Consent Form
Authorizes us to dilate your pupils during your eye exam, which allows a full view of the retina.
Download Dilation Consent PDF
HIPAA Liability Waiver
Provides your consent regarding how we may use and disclose your medical information.
Download HIPAA Liability Waiver PDF
HIPAA Notice of Privacy Practices
Outlines your privacy rights and how your protected health information is handled at our practice.
Download HIPAA Notice of Privacy Practices PDF
Helpful Tips
- Please arrive 15 minutes early to your first appointment.
- Bring a valid photo ID, insurance card, and a list of current medications.
- If you wear glasses or contacts, bring them with you.
- Expect your eyes to be dilated — bring sunglasses and consider arranging a ride.
Ready to Make An Appointment?
Your eyesight matters, and we make it easy to get the care you need.
Schedule your appointment today.