Patient Paperwork Completion/Letter Request

Patient Name*
Today's Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Did you or will you miss school/work/trip?*

YesNoNot Applicable
If so, what dates?
Reason school/work/trip was/will be missed:*
Type of Form: (i.e., FMLA, insurance, disability, letter, etc.):*
How would you like to receive your form? (Fill in all that apply)*
If picking up, which location would you like to pick up from:

ProspectPrecisionSkylineCenterraFox Run
When do you need your form/letter? Please note paperwork can take up to 1 week to complete.*

MonthDayYear
Date
Any additional informationthat we need to know?
Authorization for the Disclosure of Health Information
Information Released From:

Eye Center of Northern Colorado 1725 E Prospect Rd Fort Collins, CO 80525
Information To Be Released To:*
Patient Signature:*
Date Signed*

MonthDayYear
Date
Parent/Guardian Signature:
Date Signed

MonthDayYear
Date
Should be Empty:

Authorization for the Disclosure of Health Information