Forms

Before you come for your appointment, your doctor might ask you to fill out a form and bring it in with you. We’ve organized the forms by category to make it easier to find the one that you will need for your appointment. Click on a form to download it. Then fill it out and bring it in with you to your appointment.

All the information you provide will be kept confidential.

Binocular Vision Clinic Forms

• BV Welcome Letter 
• BV History Form (Adult)
• BV History Form (Child)
• BV Financial Agreement 
• BV Financial Agreement (Spanish)
• BV Perceptual Skills Assessment

Medical Records Authorization Form

Patients are encouraged to access their medical records at no cost through MyChart, our secure online patient portal. Many records, including visit summaries, test results, and clinical documents, are available for immediate download.

Use the link below to download a medical records authorization form.

• Medical Authorization Form

Medical History Form

• Confidential Medical History Form

Myopia Clinic

• Myopia Informed Consent for Treatment
• Myopia Clinic Information and Policies
• Instructions for Orthokeratology Lens Wearers

Low Vision Clinic Form

• Low Vision Clinic Patient Information Form

Referral Form

If you are a primary care physician or other provider and are referring a patient to us, please fill out this form and fax or email it to us.

• Fax: (510) 642-8012
• Email: caleyecare@berkeley.edu
• Referral Form

Refractive Surgery Form

• Refractive Surgery Medical History Form

Sjögren’s Medical History Form

• Dry Eye Assessment Form
• Sjögren’s Medical History Form

Special Visual Assessment Clinic

• SVAC Policies Form

Sports Vision Forms

• Brain Injury Symptom Checklist
• Convergence Insufficiency Form
• Sports Vision and Concussion Clinic Policies