CHARLES L. SCHAFFER, MD, FAAO
Ophthalmology — Sun City, Sun City West, Surprise & Anthem
Patient Forms

Patient Registration

Patient History

Acknowledgement:
Receipt of Privacy Practices

Refraction Exam Authorization

The first step towards better vision is to schedule an appointment. Please call our office at (623) 584-9295 or complete the appointment request form below.

Our scheduling coordinator will contact you to confirm your appointment. Please print and fill out all four forms, as seen on the right, before your appointment.

Please do not use this form to cancel or change an existing appointment.

Are you a current patient?
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Name:
Phone:
Email:
Preferred day(s) of the week for an appointment?
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Preferred time(s) for an appointment?
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Best time(s) to call?
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Please describe the nature of your appointment (e.g., consultation, check-up, etc.):
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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