Patient Forms

Please print and fill out the following forms. Save time at your appointment by bringing them with you when you come in for your exam.

Online Forms

Patient Registration Form

Financial Form

Optomap Form

ABN

HIPAA Privacy Form

HIPAA Acknowledgment

Printable Forms

HIPAA Acknowledgement

We are now open for routine eyecare. Our office will remain closed on Saturdays. To ensure the safety of our staff and patients, we have adopted protocols to comply with the recommendations of the CDC.

We are requiring all patients and staff to wear masks.
We have limited our patient flow to ensure safe social distancing.
Only the patient with an appointment will be allowed in the office.
Patients under 18 years old may be accompanied by one parent.
We have implemented patient, staff screening protocols. Patients are required to wash their hands upon entering the office. Staff will sanitize every staff and patient contact area before and after each patient.
If you need to select new glasses, pick up glasses or contacts or have glasses repaired we ask that you call first.
Upon arriving at the office for any services please call 703-753-6633 to allow us to greet you outside.
If you or someone in your household is ill please reschedule your appointment.

David R. Gore, O.D., PC