Patient Information Forms

These forms may be downloaded to complete before your Drs. Holcomb And Associates Office Visit.

This will speed up your visit, shorten your wait time and assist you in making sure you have all the needed information at the time of your visit.

To read and print these forms, you will need to have Acrobat Reader on your computer.

If you do not have the program, you may download it now FREE by clicking on the

Adobe Reader Logo Here or below.

Please Note:

If you have a question as to which forms you may need, please call the office. (770-590-8951) Otherwise, we need a complete copy of each for our records.

If you are a NEW PATIENT, all forms will be needed.

Use your browser's BACK button to return to this page.

Forms List: (click on each to download)

•  Welcome To Our Office (Patient Information)

•  Health Information Use and Disclosure

(Please complete the top portion of the HIPAA form but bring the full sheet with you,

the lower portion is for the staff to complete.)

•  HIPAA Privacy Practices Acknowledgment Of Receipt

•  Dilated Pupil Examination Permission Form

•  Optomap Retinal Exam Information

If you have a fax machine available,

you can fax your completed forms, with a cover sheet, to 770-590-8135

[ Home ]

Send mail to bandfpro@comcast.net with questions or comments about this web site.
Copyright © 2009 Dr. Holcomb And Associates
Last modified: 01/13/10