Bennett S. Romanoff, MD
Chief of Ophthalmology
Flower Hospital
Flower Hospital Medical Office Building
5300 Harroun Road Ste 112
Sylvania, OH 43560
419-885-5556
Romanoff Vision Logo Eye

Patient Forms

Here is the list of forms which all new patients need to have with them at their initial appointment.


The first is an "archive" of all six forms in one file. For most patients, this is the one to choose, because it will take the least time to download. The file is compressed in the "Zip" format. Windows users can "right click" on the filename (click with the right mouse button) and choose "Extract All". This one file contains all six of the forms listed below. When extracted, they can be viewed and printed using Adobe Acrobat® Reader. AllForms.zip


The rest of these are individual forms. When you click the link, they will open in your web browser for printing:

Computer User Form
Eye Medical History
HIPAA Disclosure
Lifestyle Form
Receipt of Privacy Document Form
Welcome Form
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