Header Logo


16020 North 35th Avenue
Suite 2
Phoenix, AZ 85053


MON - THUR - 9:00AM - 6:00PM
TUE - 9:00AM - 6:30PM
FRI - 8:00AM - 2:30PM

  • Btn

Patient Forms

[dt_divider style=”thin”][dt_gap height=”20″][dt_call_to_action content_size=”normal” text_align=”left” background=”fancy” line=”true” style=”1″ animation=”none”]

Fill out our new patient history form and former patient history form online now!

[dt_button size=”big” animation=”none” color=”orange” link=”https://eyehealthinfo.com/welcomeApp/?practiceName=Gong_AZ_398″ target_blank=”true”]OFFICE PATIENT PORTAL[/dt_button][/dt_call_to_action][dt_gap height=”20″]

We ask that you arrive 20 minutes early with the requested forms completed so that we can spend your allotted appointment time with you productively. Please bring any other pertinent eye information with you (ex. glasses, contact lens info, and/or prior exam results). Due to new HIPAA rules, it will be your responsibility to contact your last eye doctor to have records faxed to us. Our fax number is (602) 375-9580. Please feel free to call us if you have any further questions or concerns at (602) 547-3255. We look forward to seeing you at your appointment.

New Patient History Form

Former Patient Update Form

Privacy Information Form

Parent Questionnaire

Teacher Questionnaire

Adult Questionnaire

New Patients (Routine Eye Exam) – Please complete the New Patient History Form and the Privacy Information Form.

New Patients (Vision Therapy Evaluation) – Please complete the New Patient History Form, the Privacy Information Form, Parent or Adult Questionnaire (for the patient), and Teacher Questionnaire if the patient is a student (Please have school teacher complete prior to first appointment). This evaluation may take more than one visit.

Former Patients (Routine Eye Exam): Please complete the Former Patient History Form.

Former Patients (Vision Therapy): Please complete the Former Patient Update Form and all appropriate questionnaire forms.