Shepard and Quinton Vision Care
Patient Forms

Completing the Patient Information, Insurance Assignment and Acknowledgement of Privacy Practices forms prior to your appointment will save you time and allow us to expedite your visit. Even with forms complete, we always recommend arriving a few minutes early. This allows time for us to review your forms and finish up any remaining registration information or questions.

You have two options for completing your Patient Information Form:

OPTION A (preferred)

  1. Visit our secure web portal and enter your information. Follow instructions to securely submit your information to our office. Click here to access the electronic Patient Information Form.

  2. Print Insurance Assignment Form and Ackowledgement of Privacy Practices Form. Bring the completed forms to your appointment.

OPTION B

Print the forms, fill them out and either bring them with you to your appointment or fax them to our office at 706-861-1799 before your appointment.

Patient Information Form
This form collects personal, insurance and medical information. Please answer all questions as completely as possible.

Insurance Assignment Form
If you want us to file your insurance, please complete this form. If you have questions about your insurance coverage, contact your employer, insurance company, or visit our Insurance Information page.

Acknowledgement of Privacy Practices Form
This form states that you have received a copy of Shepard & Quinton Vision Care’s “Notice of Privacy Practices (HIPAA)” document. See next document.

Notice of Privacy Practices (HIPAA)
This document describes Shepard & Quinton Vision Care’s privacy practices and is for your information. We do not need a copy of this document.

Viewing and Printing Forms - You will need a pdf reader installed on your computer in order to view and print these forms. If you do not have a pdf reader installed on your computer you can get one free by going to:

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