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Fill Out a Patient Form

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  • Please fill out the form below and submit it prior to your appointment. We will have your paperwork ready and completed for you when you arrive. Dr. Glasser sees patients on time.

  • Medical History

  • (If you don't have any eye problems at this time, please write: None.)
  • (Check all that apply) If none, please check 'None of the above.'
  • (If no medication is taken at this time, please write: None.)
  • The Optomat retinal exam is a quick and simple way to view your retina at the start of your exam without drops and dilation. This exam allows Dr. Glasser to detect early signs of ocular disease such as Glaucoma, Macular Degeneration, Hypertension and Diabetes.

    Please click here to see the video and to learn more.
  • Why these questions are important?

    Much of our work and leisure time is spent looking at computers, cell phones, tablets and televisions. The answers to these questions will allow Dr. Glasser to determine the right prescription and other postural recommendations that will allow you to work and play more comfortably.
  • Time you spend on the Computer

  • Type of work you do on the Computer

  • (Check all that apply.)
  • While working on the computer

  • The Environment around you

  • Vision and Health

  • (Check all that apply.)
  • Privacy Policy and Acknowledgement

    We are required by law to protect the privacy of your medical information and to provide you with the following written Notice describing HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.

    This notice is effective 2/6/03 until further notice.

    By law, we may use or disclose to others your medical information for purposes of providing or arranging for your health care, the payment for or reimbursement of the care that we provide to you, and the related administrative activities supporting your treatment.

    We may be required by law, regulations, or circumstances to use and disclose your medical information for certain purposes without your authorization. Under other circumstances we may need your written authorization (that you may later revoke) in order to use or disclose your medical information.

    As our patient, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting that information, obtaining an accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.

    We have available a detailed NOTICE OF PRIVACY PRACTICES which fully explains your rights and our obligations under the law. We may revise our NOTICE from time to time. The Effective Date at the top right hand side of this page indicates the date of the most current NOTICE in effect.

    You have the right to receive a copy of our most current NOTICE in effect. If you have not yet received a copy of our current NOTICE, please ask at the front desk and we will provide you with a copy.

    If you have any questions, concerns or complaints about the NOTICE or your medical information, please contact Dr. Glasser.

  • If you have not scheduled your appointment, you may use our online appointment request form or give us a call at (202) 223-3530.
  • This field is for validation purposes and should be left unchanged.

My contact lenses had been drying out at work to the point where I didn’t even wear them most days. Dr. Glasser told me that the patient isn’t fit to the contact lens; the contact lens is fit to the patient. After determining my needs, environment and habits, we went with Proclear lenses. They not only worked for me at the office, but now, I wear them every day of the week. It just takes the right doctor to fit the right lens. Thank you soooo much.

— Joan Antiville

Stephen L. Glasser OD, PC
900 17th Street NW Suite 400, Washington, DC 20006
Phone: (202) 223-3530