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61 Camino Alto Suite 100A, Mill Valley, CA 94941

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Patient Forms

Click on the links below to print and fill out forms.

Patient Registration Form:

Privacy Practices Form:

Questionnaires:

  1. Health Questionnaire for Adults & Children
  2. Developmental Questionnaire
  3. Basic Checklist for Children
  4. Advanced Checklist for Children
  5. Questionnaire for Adults with Lazy Eye/Eye turn (Amblyopia/Strabismus)
  6. Questionnaire for Children with Lazy Eye/Eye turn (Amblyopia/Strabismus)
  7. Questionnaire for Patients with Traumatic Brain Injury/Post-Concussion
  8. Symptoms Checklist for Sensory Motor Delay
  9. Visual Perception Checklist
  10. Convergence Insufficiency Checklist

Educational Guides:

  1. Teacher-Parent Vision & Learning Guide
  2. Professional Endorsement of Vision Therapy
  3. Binocular Vision Checklist
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Please read our updated message related to health and safety precautions prior to your visit to Mill Valley Optometry.