Online Form


At Herkert Family Eye Care, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment. If you are new to our office, please fill out each of the forms below.

If you are a returning patient, please fill out the Statement of Financial Responsibiility and the Lifestyle Questionnaire.

  • You will need AdobeReader® to download and complete the forms.

  • Download the required form(s). Print out the form(s) and complete the required information.

  • Fax your printed and completed form(s) to our office or bring them with you to your appointment

New Patient Paperwork

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