request an appointment online designer eyewear contact lenses download patient forms Contact Playa Del Rey Optometry Office

Patient Forms


Your Health History

Web Registration
We know your time is valuable so in an effort to cut down your time spent in the office filling out forms, we have included them here. Just print them out, fill them out, and bring them with you. It’s that easy!

Financial Responsibility

Cancellation Policy

Notice of Privacy Practices
Aviso de las Prácticas de Privacidad

Acknowledge Receipt of Privacy Practices & Consent Form
Recibo del Aviso de las Prácticas de Privacidad y el Formulario de Consentimiento

Return Policies
Póliza de Devolución

It is the policy of Del Rey Optometry not to discriminate on the basis of race, color, national origin, sex, age or disability. Del Rey Optometry has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. § 18116) and its implementing regulations at 45 C.F.R. pt. 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities.  Read our Nondiscrimination Policy & Notice.

get-adobe-readerThese PDFs require a free plugin that may have come included with your browser. If you are having difficulties opening these files visit Adobe’s web site for Adobe’s PDF reader.