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Located in Kennett Square, PA - Across from the CVS
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Office Forms

These forms are best viewed with Adobe Acrobat Reader, which can be downloaded for free on their website at http://www.adobe.com/.

ENTRANCE/HEALTH HISTORY FORM – This information may be securely uploaded directly to our system by clicking the “Fill out your information online” link on the home page (or to the right). We are completely electronic so this saves both time and paper so we highly recommend this option. If you prefer to print the pages out, you may download our Entrance/Health History form here and we will input it to our system by hand when you arrive to our office. If it is your first time to our office, you will also need to bring a copy of the Privacy Consent form listed below (if you do the online option, we will take care of that when you get to the office).
MEDICAL RELEASE FORM – This form is used if you would like to authorize Ganly Vision Care to release your records to third parties. You may simply complete the form and fax it to our office. It is not needed for normal office visits.
PRIVACY CONSENT – In regards to HIPPA (the Federal Health Insurance Portability and Accountability Act), as of April 14, 2003, this form must be signed by all patients prior to your office visit. For the more lengthy version (which goes into more specific details), please see the Notice of Privacy Practices form.
CONTACT LENS PRICE PROMISE – Please view this form for information regarding our contact lens pricing philosophy.
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All Patients-Please Click Here Regarding New Office Protocols for COVID-19