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Vision Care Direct

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ONLINE FORMS

Forms below with asterisks (*) are editable and can be filled out online, then either submitted electronically (via the e-mail submit button) to our office, or printed at home so that you can bring the paperwork into our office at the time of your appointment. Please ensure you have the most current version of Adobe Acrobat Reader installed on your computer by clicking on the icon below.

Adobe Acrobat Reader

Alternatively, you may print and fill out any form manually and either fax it to our office at (623)975-7005, or hand carry them in at the time of your appointment.
Please fill out the six forms, in Red, if you are either coming in as a new patient, or for a cosmetic consultation. Please fill out all forms in Red and Blue if your appointment is for an annual eye examination. Thank you.


Patient Registration Form

Health Questionnaire

HIPAA Privacy Form

Patient Registration Form

Health Questionnaire

HIPPA Privacy Policy Form



Financial Policy

Refraction Form

Financial Policy

Patient Permission for Verbal Communication Form

Refraction Form



Medical Record Release*

 

Medical Record Release Form

 

We Accept the Following Credit Cards:
Credit Cards Accepted, Visa, MasterCharge, Discover, Amex
Apply Now - Care Credit
19052 R.H. Johnson Blvd.
Sun City West, AZ 85375
623-975-2020
10701 West Bell Road
Sun City, AZ 85351
623-876-2020
500 Savage Street
Wickenburg, AZ 85390
928-684-2020

This website does not contain medical advice and the use of this website does not create a physician/patient
relationship between you and Dr. Emilo Justo or Arizona Eye Institute and Cosmetic Laser Center.

The photographs of models displayed on the headings, procedures pages and/or borders of this web site are for
decorative purposes only. See before & after photos of Dr. Emilo Justo patients to see possible results.

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