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Forms

Each form can be filled out on your computer. After filling out, please print and sign by hand.

  • Patient History Form
  • Patient History Form
  • Records Release Form
  • Records Release Form
  • HIPAA Form
  • Authorization to discuss your information
  • Authorization to perform additional testing
  • Patient education sheets on various topics
  • Dry Eye
  • Glaucoma
  • Macular Degeneration
  • Diabetic Retinopathy

Contact Us
if you any questions about our PDF forms.

The best compliment we can receive is a referral from our current patients. Thank you for your confidence.

Copyright

  • © 2012 Harmony EyeCare. All Rights Reserved.
  • Please Read Our Privacy Policy
  • Updated: January 2012

Contact

  • 111 South Red Bank Rd, Ste B
  • Evansville, IN 47712
  • drverbeck@harmonyeyecare.com
  • 812.423.4984 / Tel
  • 812.423.5029 / Fax
  • Office Hours

Methods of Payment

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  • Care Credit