Office Forms
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Please fully complete and send us the Registration Form and Medical History Form prior to your appointment. Completing the forms beforehand will enable us to provide you with more prompt attention at the time of your exam. We offer those who submit their completed forms prior to their examinations $5.00 toward their eyewear and/or contact lens purchase. If you are unable to complete the forms prior to your appointment, please arrive 15 minutes early to allow enough time to fill them out.
You may complete these forms in one of the following ways:
1. Type in the information into the highlighted fields and save it to a file in your computer (the fill-ins will otherwise will be submitted blank). E-mail the form(s) via attachment to: reception@broadwayvision.com, or fax from your computer to (206)464-0572.
2. Type in the information into the highlighted fields and print the forms. Bring them in with you at the time of your appointment, or fax it beforehand to: (206)464-0572.
3. Print the forms and write in the information. Bring the completed forms with you at the time of your exam.
Please sign and date page 2 “Payment and Insurance Information”
Thank you!
The Broadway Vision Source Team
Patient Registration Form
If you are new to our office, please complete the Registration Form
 Registration PDF
Medical History
-If you are new to our office, please complete the Medical History Form
-For former patients, please indicate any change(s) in your medical history since your last examination.
If there is no change, please complete your name, today's date, and check the box on page 3.
Medical History Form PDF
Contact Lens Exam
This form is only applicable to those patients who wear contacts now, and are scheduled for a 'Comprehensive Eye Exam with a Contact Lens Evaluation'.
ContactLensExam PDF
Notice Of Privacy Practices
Please keep the first two pages for your records, and to sign the third page and bring it to your appointment.
PrivacyPractices PDF
Optomap ABN Form
Please read and complete this form regarding Optomap retinal imaging.
Optomap PDF
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