SureVision Patient Forms

Patient Appointment Forms:


Medical Record Forms:

Release to Send Medical Records FROM SureVision

HIPAA Forms:

HIPAA Notice of Privacy Practices
HIPAA Consent Form

Vision Testing Forms:

Amsler Grid (Home Test for Macular Degeneration)

For your convenience, we have made a number of forms available for patients to download, complete and submit on-line. Completing and returning these prior to your first visit will minimize the time you spend in the waiting room (or in your vehicle) filling them out when you get here. The other forms on this page are informational. If your doctor has given you a form with specific information or instructions different from the information on these online forms, rely on the information given to you by your doctor, not on the online forms. If you’re not sure which forms you need, please call 314-921-2020 for assistance.

Completed Forms

The completed forms can be returned to us by several methods. Since some of the forms do contain confidential information, please return them by whichever method you can send securely and safely.

  • submit online after completion
  • e-mail to
  • fax to 314-863-9977
  • mail or bring to your nearest SureVision Eye Centers location
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At SureVision Eye Centers,
Vision Like You’ve Never Seen Before™

The surgeons and doctors at SureVision Eye Centers are among the most experienced and well-trained in the world. Each year, they perform thousands of surgical and vision correction procedures. At SureVision Eye Centers, we believe everyone should have a lifetime of their best possible vision.

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