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 Online Patient History Form

Welcome!

New Patients -Click here to complete your information & medical history  before your appointment.

 

Online Patient Portal

Had your Exam? Click here to view your records online.  Login & password information will be uploaded during your appointment.

 

 

Contact Lens Insertion & Removal Training Video

 (Note: You may watch this video in preparation for your in office training, however, the video does not take the place of the in office training.)

 

 

Notice of Non-Discrimination - ACA Section 1557

 

Mountain Vista Eyecare and Dry Eye Center complies with applicable Federal civil laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Mountain Vista Eyecare and Dry Eye Center does not exclude people or treat them differently because of race, color, national origin, age disability, or sex.

Mountain Vista Eyecare and Dry Eye Center:

*Provides free aids and services to people with disabilities to communicate effectively with us, such as:

* Qualified sign language interpreters

               *Written information in other formats (large print, audio, accessible electronic formats, other formats)

*Provides free language services to people whose primary language is not English, such as:

               * Qualified interpreters

               * Information written in other languages

If you need these services contact the Section 1557 coordinator at Mountain Vista Eyecare and Dry Eye Center.

If you believe that Mountain Vista Eyecare and Dry Eye Center has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disabililty, or sex, you can file a grievance in person or by mail, fax, or email. I f you need help filing a grievance, our Section 1557 Coordinator is available to help you.

Mailing Address: 7761 Shaffer Parkway, Suite 200, Littleton, CO 80127

Telephone: 303-979-4505

Fax:  303-933-0714

You can also file a civil rights complaint with the U.S. Departments of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

 

Nondiscrimination and Language Assistance:

SPANISH:  Mountain Vista Eyecare and Dry Eye Center cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-360-3140025 (TTY: 1-855-295-9177).

 

 VIETNAMESE:  Mountain Vista Eyecare and Dry Eye Center tuân thç lu­t dân quyÁn hiÇn hành cça Liên bang và không phân biÇt Ñi xí dña trên chçng tÙc, màu da, nguÓn gÑc quÑc gia, Ù tuÕi, khuy¿t t­t, ho·c giÛi tính.

CHÚ Ý: N¿u b¡n nói Ti¿ng ViÇt, có các dËch vå h× trã ngôn ngï miÅn phí dành cho b¡n. GÍi sÑ 1-360-3140025 (TTY: 1-855-295-9177).

CHINESE: Mountain Vista Eyecare and Dry Eye Center uˆi(„o¦ Ջš à.ÏšrÏ@qta˜œ'% g–ûUº

 

 è‚œ¨(AÔ-‡ ¨ïåM»r—žô© ÙËôû 1-360-3140025 (TTY: 1-855-295-9177).

 

KOREAN: Mountain Vista Eyecare and Dry Eye Center @(”) ( ð) õüŒ•D Xp x…, <€É, œà m, ð9, ¥` ” 1ÄD t \ (ÄXÀ JµÈä.

 

 üX: \m´| ¬©Xܔ ½°, ¸´ ÀÐ D¤| 4Ì\ t©Xä  ˆµÈä. ˆ<\ Tt üíÜ$. 1-360-3140025 (TTY: 1-855-295-9177).

 

RUSSIAN: Mountain Vista Eyecare and Dry Eye

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AMHARIC: Mountain Vista Eyecare and Dry Eye Center èLð+ 2j ev}• eu èë¨e- 2• 0Î}• `Ø-a `Fó @c `Ø- ( c `¥õc `£« óu Èí `>s •›Í• 0Í £ë b

 

 5sÈ;: è“)u K•K £-› ¨ èu-  ¥-ós õ-v}c `; ë ÝÎu pØ pË a Èð ¨pÍ A%- íðÍ (5u p3“xÍ: 1-360-3140025 (TTY: 1-855-295-9177).

 

ARABIC:  Mountain Vista Eyecare and Dry Eye Center ÌD*2E

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GERMAN:  Mountain Vista Eyecare and Dry Eye Center erfüllt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht ab.

 

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-360-3140025 (TTY: 1-855-295-9177).

 

FRENCH:  Mountain Vista Eyecare and Dry Eye Center respecte les lois fédérales en vigueur relatives aux droits civiques et ne pratique aucune discrimination basée sur la race, la couleur de peau, l'origine nationale, l'âge, le sexe ou un handicap.

 

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-360-3140025 (TTY: 1-855-295-9177).

 

NEPALI: Mountain Vista Eyecare and Dry Eye Center 2 */M$ 8@/ Àl'>0K 5M/58M%>8H *>2(  0 56, 0, 0>?7MM0/$>, .0, *>M$> 5> Àg2MK '>0.> -G&->5 &À7( d

 

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TAGALOG: Sumusunol ang Mountain Vista Eyecare and Dry Eye Center sa mga naaangkop na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan o kasarian.

 

PAUNAWA: Mountain Vista Eyecare and Dry Eye Center Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-360-3140025 (TTY: 1-855-295-9177).

 

JAPANESE: Mountain Vista Eyecare and Dry Eye Centeroi(UŒ‹#¦l)ՒuˆWº.Œnrú«ýtbœ³~_o'%kúeOî%’D_W~[“

 

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CUSHITE: Mountain Vista Eyecare and Dry Eye hariiroo hawwaasummaa Fedeeraalaan wal qabatan sanyiidhaan, bifaan, dhiigaan, umriidhaan, hiri’ina qaamaan, yookiin koorniyaadhaan hin loogu.

 

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-360-3140025 (TTY: 1-855-295-9177).

 

PERSIAN: ©HG E4'G/G Eyecare H .4© †4E E1©2 E7'(B (' BH'FÌF A/1'D -BHB E/FÌ B'(D ',1' H FG *E'J2 FJ2 (G ©'1 *H37 9DD F˜'/ 1F¯ EDÌ* 3F F'*H'FÌ Ì' ,F3Ì.

 

*H,G: '¯1 -1A A'13Ì 2('F ©E© ./E'* 1'̯'F (G 4E' /1 /3*13 G3*F/. 1-360-3140025 (TTY: 1-855-295-9177).

 

KRU: Mountain Vista Eyecare and Dry Eye complies with the federal civil rights laws applicable and does not discriminate on grounds of race, color, nationality, age, disability or sex.

 

Attention: if yu speak kru, yumi smak daun assistance services, free of charge, are available to yu. Yumi call 1-360-3140025 (TTY: 1-855-295-9177).

 

IBO: Mountain Vista Eyecare and Dry Eye complies na Ídabara akpa ókè na ndabere nke agbårå; åcha akpåkpÍ, mba o, afÍ, nkwarå, ma Í bå mmekÍahå.Federal ruuru iwu na adËghË

 

 NtË: Ì bårå na aså Ibo, asåså aka Íaså n’efu, defu, aka. 1-360-3140025 (TTY: 1-855-295-9177).

 

YORUBA:  Mountain Vista Eyecare and Dry Eye

t¹le ilana ofin ijÍba apapÍ lori etÍ arailu ati pe wÍn ko gbÍdÍ sojucaaju lori ÍrÍ ¹ya, àwo, ilu-abinibi, ÍjÍ-ori, abarapa tabi jij¹ Íkunrin tabi obinrin.

 

AKIYESI: Bi o ba nsÍ èdè Yorùbú Ífé ni iranlÍwÍ lori èdè wa fun yin o. ¸ pe ¹rÍ-ibanisÍrÍ yi

1-360-3140025 (TTY: 1-855-295-9177).