Appointment Forms for our Eye Exams

For your convenience, the following forms are readily available for you to download and print. At the time of your appointment, we request that you provide us with completed copies of the following Welcome Form, Medical History Questionnaire, and Patient History. If you’re currently experiencing headaches, please complete the Comprehensive Case History for Headaches as well.

Please be sure to bring all insurance information at the time of your appointment. We can make copies of your insurance card(s) at that time.

Please contact us here if you have any questions about our forms or eye doctors & exams


Download the Free AdobeReader®

Contact Us

We look forward to hearing from you.

Location

Find us on the map

Hours of Operation

Our Regular Schedule

MA Shurtz OD & Associates

Monday:

8:00 am-5:30 pm

closed for lunch from 12:00 pm to 1:15 pm

Tuesday:

8:00 am-5:30 pm

closed for lunch from 12:00 pm to 1:15 pm

Wednesday:

8:00 am-5:30 pm

closed for lunch from 12:00 pm to 1:15 pm

Thursday:

8:00 am-5:30 pm

closed for lunch from 12:00 pm to 1:15 pm

Friday:

8:00 am-1:00 pm

Saturday:

Closed

Sunday:

Closed