Patient Forms

Chicago, Illinois

Patient Registration Documents:

Patient History Form (click to fill out)
HIPAA Packet (pdf)
HIPAA Packet Signature Form (click to fill out)
HIPAA Contact Form (click to fill out)

Permission for Release of Patient Medical Records (pdf)
Do you want to have your records sent to our office? (pdf)

Refractive Surgery Documents:

LASIK Packet (pdf)
PRK Packet (pdf)
FDA Laser Information (pdf)

Cosmetic Treatments:

Botox (pdf)
Juvederm (pdf)

Doctors for Visual Freedom Laser Center

875 North Michigan Avenue, Suite 1550
Chicago, IL 60611

The Chicago LASIK professionals of Doctors for Visual Freedom present this website to provide information about LASIK eye surgery and related procedures and treatments for informational purposes only. It should not be construed as medical advice. If you have questions about Latisse, LASIK, BOTOX®, Juvederm or any other cosmetic or vision correction procedure, please contact our ophthalmology team today. Doctors for Visual Freedom serves patients from Arlington Heights, Downtown Chicago, Buffalo Grove, and throughout the Chicago area.

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The John Hancock Center, 875 North Michigan Avenue, Suite 1550, Chicago, IL 60611
2010 S Arlington Heights Rd, Suite 121, Arlington Heights, IL 60005

Patient Forms

Chicago, Illinois

Patient Registration Documents:

Refractive Surgery Documents:

Cosmetic Treatments:

Ask Dr. Mark!