Patient Forms

Request Appointment

All the Information You Need in One Place

Take a look through our forms to learn more about our practice policies and processes.

If you have any questions or concerns regarding the information on this page, please contact us. We’re here to ensure you have everything you need to start your eye care experience with confidence and comfort.

Forms

Click the boxes to the right to access forms and information relevant to your experience. 

If you are already a patient with us and need information specific to you, log in to our Patient Portal. From our Patient Portal, you can pay for treatments, book appointments, request prescriptions, and more.

New Patient Form

Click here to start your journey with us.

We uphold a high standard for privacy and confidentiality. Click here to learn about how we keep your information safe.

Lake Eye Associates policy requires a parent or legal guardian to accompany all minors under 16 years of age when visiting our team or undergoing treatment.

Patients between 16 and 18 may come in for follow-up appointments on their own. However, we still require a parent’s or guardian’s permission by filling out the Permission to Treat a Minor form below.

Patients over 18 are considered adults under HIPAA laws. Parents and legal guardians may not have access to another patient’s health history without the patient’s explicit consent, regardless of who is paying for their treatment or providing insurance.

Please fill out this form:

Our office is dedicated to maintaining the privacy of your Protected Health Information (PHI). This includes such data as your name, address, phone number, date of birth, Social Security number, account information, medical record number, or any other unique identifying number.

In conducting our business, we will maintain records regarding you and the treatment and services provided to you. We are required by law to maintain the confidentiality of health information that identifies you.

Please fill this form to authorize the release of your medical records to our practice.

Brochures

Learn about eye conditions, diseases, treatments, and more by clicking any of the brochures on this page. If you have further questions regarding your eye health or the treatments we offer, please feel free to contact our team.

Get Eye Smart
American Academy of Ophthalmology

Beyond Cataracts
Cataracts are more common than you may know, but they can also be treated. Learn about how to reclaim your vision

Care Credit
Convenient monthly payment plans. The easier way to get vision care.

Would You Like To Learn More? Contact Us Today

Our team Lake Eye Associates is ready to provide life-changing solutions for your vision problems today. Book your appointment or get in touch with us if you have any further questions.

Our Locations

    We are a proud partner with US Eye, a group that provides patient-first, sophisticated,
    unrivaled care in ophthalmology, optometry, dermatology, and more.
     

    Testimonials

    Get social on Facebook

    Cover for Lake Eye Associates
    1,181
    Lake Eye Associates

    Lake Eye Associates

    Find everything you need for healthy vision from Board Certified ophthalmologists Scott Wehrly MD, Shelby Terpstra DO, Scot Holman MD, Vinay Gutti MD and Jose Vazquez MD, and Optometrists Adria Young OD, Lindsey Walsh OD and Alexandria Rawls OD

    This message is only visible to admins.
    Problem displaying Facebook posts.
    Click to show error
    Error: Server configuration issue
    instagram facebook facebook2 pinterest twitter google-plus google linkedin2 yelp youtube phone location calendar share2 link star-full star star-half chevron-right chevron-left chevron-down chevron-up envelope fax