Online Forms


At Preferred Eye Care, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.

  • You will need AdobeReader® to download and complete the forms. Click here to download.
  • Download the required form(s). Print out the form(s) and complete the required information.
  • Fax your printed and completed form(s) to our office or bring them with you to your appointment. 

Patient Checklist - Required

To help us provide you with the best care and in office experience, we are asking you to please read over and make sure you complete the following items on this form.

Download & Print Form


New Patient Form - Required

To help us provide you with the best possible care and ensure a smooth, efficient visit, please download, print, and complete the New Patient Form and bring it with you. Having this information in advance allows us to prepare for your visit and streamline the check-in process.

Download & Print Form


New Patient Health History Form – Required

Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals your have regarding your eye health or vision on the form.

Download & Print Form


Request for Medical Record Release of Information

Download & Print Form

Download the Free AdobeReader®

Primary Location

Address

406 Dallas Ave,
Selma, AL 36701-5746

Fax

Secondary Location

Address

931 US-80 Suite A,
Demopolis, Alabama 36732

Phone

334-289-8795

Fax

Office Hours

Monday  

8:00 am - 1:00 pm

2:00 pm - 5:00 pm

Tuesday  

8:00 am - 1:00 pm

2:00 pm - 5:00 pm

Wednesday  

8:00 am - 1:00 pm

2:00 pm - 5:00 pm

Thursday  

8:00 am - 1:00 pm

2:00 pm - 5:00 pm

Friday  

8:00 am - 1:00 pm

Saturday  

Closed

Sunday  

Closed