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At RANCHO DEL REY OPTOMETRY, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.  Please fill out a separate form for each person having an appointment.

  • You will need AdobeReader® to download and complete the forms. Click below to download AdobeReader®.
  • Download, print, and complete the required form(s). 
  • Download, print, and complete a Vision Insurance form, if applicable.
  • Bring the completed form(s) with you to your appointment.
  • Arrive 15-20 minutes early to your appointment to allow for traffic, parking, and form processing.  Please do not arrive any later than your appointed time.
  • Expect your time in-office to be approximately 1hour, add an additional 30-40 minutes if eye dilation is requested or required.

Patient Health History Form – Required

Please complete this form as it lets us know the history and current state of your health. 

HIPPA Form - Required

Please sign this form to acknowledge how your health information is protected.  At RDR Optometry we do not disclose any of your personal information to anybody except how demanded by Law or for insurance and payment processing.

60-Day Prescription Service Guarantee - Required

Please print, read, and sign to acknowledge the Office Policy.  Our Service guarantee explains how you and your Doctor help each other to get the most of your vision and time together.

Download & Print Health History Form/HIPPAA/60-Day Service Guarantee Forms

Vision Insurance Forms

Please note that Vision Insurance is typically a separate entity from Medical Insurance.  RDROptometry is not a provider for Medical Insurances in any form.   

As the direct or affiliate provider for the following Vision insurances, we will verify exam benefits and co-pays, obtain an exam authorization and process the exam claim for you.  We currently accept:

Vision Service Plan (VSP) - Download and complete the VSP Insurance Form

Medical Eye Services (MESVision) - Download and complete the MESVision Insurance Form

United HealthCare Vision/Spectera - Download and complete the UNHVision/Spectera Vision Insurance Form


Download the Free AdobeReader®