Amy V. Harper, O.D., P.L.L.C.

- New Patient Information -
853 Old Winston Road, Suite 113, Kernersville, NC 27284
336-993-3930 (336-993-EYE0) - 336-993-3979 FAX

- Email Dr. Harper -

 

If you would like for us to have access to your previous medical records, please download the Medical Records Release Form on this page and submit it to your previous eye care provider. This gives them permission to send us copies of your previous exam notes.

Also on this page are copies of forms that we routinely have new patients complete on their first visit. If you prefer, you may download these and bring the completed forms to your appointment to minimize the amount of paperwork you will need to complete in the office. If you are unable to download these forms, we are happy to provide you with copies at your visit. All items listed below are required.

If you are unable to download these forms, or you prefer to fill them out in the office, please arrive 15 minutes prior to your appointment to complete the paperwork.  We ask this in an effort to keep patients on schedule.  If you arrive 15 minutes or more late for your appointment, and your paperwork is incomplete, you may be asked to reschedule as to not disrupt other patients scheduled exams.

These forms are in PDF format. You will need Adobe Reader to view them.

http://www.adobe.com/products/acrobat/readstep2.html

Click here to get a free copy of Adobe Reader.

 


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