Zanesville Vision Source Zanesville, Ohio Patient Forms

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Zanesville Vision Source Zanesville, Ohio Patient Forms

This is your place for important forms, from new patient registration forms to our privacy policy and program enrollment forms. If you have any questions while filling out your forms, don’t hesitate to contact us for assistance.

You are filling out forms for our Zanesville Vision Source Zanesville, Ohio location.

New Patient Form

Pleasefill out this patient data sheet so that we may better understand your general health and visual condition.

Download Form

HIPPA Privacy Form

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

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Lifestyle Index

This questionnaire is meant to help your doctor understand what you're experiencing on a regular basis - whether it's caused by your eyes, posture, stress, etc. Your responses will help make sure you receive the best care possible.

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Optomap

Dr. Rice and Dr. Galloway recommend the Optomap Retinal Imaging. It is a 3-D image of the back of the eye (the Retina) and is painless, non-invasive, with no side effects.

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Our Brands

We want you to love your glasses and contacts, from the way you look and feel, to the way they improve your everyday life. At Trillium Vision Care, we’re proud to offer a huge range of eyewear styles and brands, including budget-friendly favorites and designer names.