Click on the name of the form to open it.
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available from the Adobe web site. Click on the Get Adobe Reader button, and follow the download directions on the Adobe web site to get your
copy of Adobe Acrobat Reader.
New Patient Information / Consent Form: Please print this form and fill
it out prior to your first visit. It gives us your basic personal information for our records.
Health History Form: Please print this form, complete it, and bring it
with you to your first visit. It gives us your health history so we may give you appropriate treatment.
Dr. Statesir's office participates with Medicare, Railroad Medicare and most Medicare HMO's.
We also participate with most Commercial and Secondary Insurers, as well as most Vision Care plans, including most VSP and EYEMED plans.
NO FACILITY FEES
Please contact your insurance company to confirm that we are included in your plan.
When you need an eye doctor or eye surgeon, contact Dr. Statesir at (216) 228-9122.