Transfer Medical Records

In preparation for your appointment with us, please complete the online form below, “Forward Records to Advanced Vision Therapy Center”. Click submit, and we'll take care of the rest.​

*Note: All fields marked with an asterisk (*) are required.
*Date
*Patient's Full Name
*Patient's Date of Birth
*Street Address*City*State*Zip Code

 

I hereby authorize the release of my medical and/or optical records and request that they be transferred from:

*Doctor
*Office
*Address
*Phone
Fax

 

My personal health information, and complete medical records may be released to the Doctors affiliated with:

Advanced Vision Therapy (please fax the requested information as noted below)

Advanced Vision Therapy Center
7960 W. RIFLEMAN STREET, #130
BOISE, IDAHO 83704, USA
PHONE: 208.377.1310
FAX: 208.489.1478

This records release is valid for 1 (one) year from the date of signing. This records request is for the purpose of continuation of care. Advanced Vision Therapy Center is not liable for any fees associated with the release of the requested information. The patient bears that liability, and requests to be notified in advance of any charges for the release of PHI and/or medical records.

The purpose of this release is to obtain:

The purpose of this release is to obtain:


 

Patient Signature
Guardian Signature (If patient is a minor)

Call 208.377.1310 to Schedule Your Assessment

Advanced Vision Therapy Center is Idaho’s premier clinic for Vision Therapy, Neuro-Optometric Vision Rehabilitation and Sports Vision Training. We offer vision assessments and customized treatment for both children and adults that are tailored to the specific vision condition of each individual.

Not sure which type of vision assessment is right for you? Call us today and we'll help you determine the best assessment to achieve your visual goals.

Request an Appointment