Personal Representative Authorization for Medical Release (English)

Thank you for choosing Eye Physicians & Surgeons of Arizona.

Please fully complete all sections of this form.

Please bring the following to your appointment:

  • Photo ID
  • Insurance Card
  • List of Medications (if any)

For your appointment, please allow 2 to 3 hours for a full evaluation, dilation, and any testing.

For cataract evaluations, please remove soft contact lenses at least 48 hours prior to your appointment and please remove hard lenses (gas permeable) at least 2 weeks prior to your appointment.

If you have any questions, please contact our office.