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Patient Forms


For your convenience, we have uploaded several documents you will need for your first appointment with us. You may download them, fill them out, and bring them in for expedited check-in!

We thank you in advance for taking the opportunity to complete these forms before your appointment. We look forward to seeing you soon!

New Patient Intake Forms

Adult Patient Intake Form (18+)
Child Patient Intake Form (17-)

Office Disclosures

This document says that you give your consent for us to contact you and bill your insurance, and you also agree to pay any applicable co-pays that may exist at the end of your visit.

Welcome to Our Office Disclosures

Convergence Insufficiency Symptom Survey

If the reason for an eye exam is any of the following: problems reading, headaches or eye strain while reading, problems in school or with homework, please fill out and bring in the following, in addition to the above paperwork.

Convergence Insufficiency Symptom Survey

OSDI Dry Eye Questionnaire

If you experience any itching, burning, watering, or other discomfort or awareness of your eyes, please fill this form out, in addition to the above paperwork, and bring it in to your exam.

OSDI Dry Eye Questionnaire

Privacy Policy (HIPAA)

This document informs you that we will not release your confidential medical information without your consent.

2019 Privacy Policy (HIPAA)

Location

Lilac Family Eye Care
23505 E Appleway Ave #106
Liberty Lake, WA 99019

(509) 210-0303
info@lilacfamilyeyecare.com
(note: this secure email is only accessible when we are physically in the office)

Office Hours

Monday 9:00 A.M. – 6:00 P.M.
Wednesday 9:00 A.M. – 6:00 P.M.
Friday 9:00 A.M. – 6:00 P.M.