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Patient Forms

Our efforts to ensure that you have a pleasant, professional experience at Glaucoma Center of Michigan start in advance of your arrival. Click the links below for forms you can download, print, and fill out at home before your appointment.

If you are interested in learning more information about a procedure or eye disorder click here for a list of our recommended links.

If you have specific questions please click here to contact us.

Please contact our office to schedule an appointment. (248) 356-0098
Open Monday – Friday from 8 a.m. to 5 p.m. Click here for directions or more information on our current locations.

New Patient Registration Forms

Click here to download, print and fill out in their entirety our New Patient Registration Forms to bring with you on your scheduled appointment by clicking the link above.

Patient Privacy Statement

Click here to view our Patient Privacy Statement.

Limited Patient Authorization

Click here to download, print and fill out our Limited Patient Authorization Form. This form is for Disclosure of Protected Health Information and will give our office the authority to provide your protected heath information (PHI) to a designated person or entity

3 Convenient Locations

Southfield Office

29201 Telegraph Rd., Suite 301
Southfield, MI 48034
Call (248) 356-0098

Eastside Office

21000 Twelve Mile Rd., Suite 108
St Clair Shores, MI 48081
Call (586) 445-1170

Dearborn Office

19853 W. Outer Dr., Suite 102
Dearborn, MI 48124
Call (313) 561-4070
(248) 356-0098
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