Patient Forms
New Patient Paperwork
Every new patient of our practice is required to complete our New Patient Paperwork prior to an initial examination. You will be emailed a link a few days prior to your appointment to complete online. If you prefer, you may also print, complete, and bring a copy of the paperwork found below.
Medical Records Release or Request
To request a copy of your personal medical records or release your records from our office to another provider, you must sign and return an authorization form. Once completed, email the form to info@retinacolorado.com or fax to (303) 261-1601. Please allow 5-7 business days for our team to process.
Colorado Retina Policies
- Good Faith Estimate
- Good Faith Estimate (Spanish)
- HIPAA Policy
- Notice of Privacy Practices
- Financial Policies
Co-pay Assistance Enrollment Forms
Financial assistance is available for certain intravitreal injection treatments, for eligible patients.
- EYLEA4U Patient Enrollment Form
- EYLEA4U Patient Enrollment Form (Spanish)
- Ozurdex Patient Enrollment Form
- Syfovre - Apellis Assist Enrollment Form | Apellis Assist
- Lucentis, Vabysmo, Susvimo
- Lucentis, Vabysmo, Susvimo (Spanish)
Payment Assistance and Grants
Good Days and other payment assistance programs provides financial support for patients who cannot afford the ocular treatment they urgently need. Contact one of our financial counselors at 303-261-1600 for more information.
Language Assistance Services
Free virtual language interpreting services are available for your appointments if your primary language is not English. We offer support in Spanish, Chinese, Vietnamese, Korean, Russian, German, French, Japanese, and over 15 other languages.
Continuous Care Program
Your whole body is connected. Your care plan should be, too. We offer a Continuous Care Program that meets your unique retina and general healthcare needs. More info HERE.
LumiThera Photobiomodulation
Consent form to enroll in the the first and only FDA-approved treatment for early to intermediate Dry Age-Related Macular Degeneration. More info HERE.
