Patient Forms


New Optometry Patients

Thank you for choosing us to care for your visual and health needs. Please call our office at (323) 954-5800 to schedule an appointment. If you are new to our office, please fill out the first four forms below. If you wear contact lenses, please also fill out the Contact Lens Questionnaire. If you are if you are seeing us for visual rehabilitation after a brain injury (such as stroke, car accident, aneurysm or brain tumor) please also fill out the Visual Rehabilitation Form.

Filling out your forms ahead of time will help us to stay on schedule. Please fill out the forms below and either FAX them to our office before your appointment (855) 897-2998, email them to, or bring them with you. Please note that there is a $35.00 Late Cancellation Fee for appointments that are changed or canceled within 48 hours of your appointment time. For Vision Therapy, a full session charge applies for missed appointments, or changes within 48 hours of scheduled appointment.

Online Forms

Please use these online forms to submit your new patient information to our front office. These online forms have the ability to directly email your filled out information to our front office staff. By utilizing our online patient information tools your waiting times before being treated will be shortened but your experience will be improved. Please email forms to Thank you!


All New Patients, Please Fill Out These Forms:

Patient History

Symptoms Checklist

Financial Policy

HIPAA Privacy Policy

If You Have Vision or Medical Insurance:

Insurance Verification Form

If You Wear Contact Lenses, or Are Interested in Contact Lenses, Fill out These Forms:

Contact Lens Service & Fees

If You've Had a Concussion, Brain Injury or Stroke, Fill Out This Form:

Visual Rehabilitation Form

Speed Dry Eye Questionnaire:


Hollywood Vision Center-Optometry
955 Carrillo Dr, Ste 105
Carthay Circle

Los Angeles, CA 90048
Phone: 323-521-4770
Fax: (855)897-2998
Office Hours

Get in touch