Patient Registration and Forms

You can prepare for your University Eye Center at Ketchum Health appointment in advance by completing the web registration or by printing and completing the necessary forms provided below. If you have any questions, just give us a call at 714.463.7500.

Patient Web Registration

Save time and paper by completing our online Patient Web Registration. 

Patient Web Registration

Patient Forms

English Version

Required for all patients

• Patient Information Form
• Health History & Lifestyle Questionnaire
• Financial Policy
• Patient Bill of Rights and Responsibilities
• Notice of Privacy Practices

Specialty forms

• Low Vision Patient Information Form
• Pediatric Health History and Lifestyle Questionnaire
• Consent Form for Treatment of Minors
• Convergence Insufficiency Symptom Survey

Spanish

Formas para todos los pacientes

• Información del Paciente
• Historia Médica y Estilo de Vida
• Politicas Financieras
• Derechos de los Pacientes
• Aviso sobre prácticas de privacidad

Formas para servicios especializados

• Servicio De Pediatriá Para Los Ojos Cuestionario Medico Y Estilo De Vida
• Autorización Para La Atención A Menores De Edad