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Patient Forms

The following forms are to be completed at check-in for new patients. To expedite the check-in process, please complete these forms and then bring them to your appointment.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de
asistencia lingüística. Llame al 1-602-242-4928.

Statement of Non-Discrimination

Associated Retina Consultants complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Associated Retina Consultants does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Associated Retina Consultants 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 and information written in other languages.

If you need these services, contact our office at 1-602-242-4928.

If you believe that Associated Retina Consultants has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Patty Baeza-HR Manager, 1750 E. Glendale Ave. Phoenix AZ 85020. Email:pattyb@associatedretina.com, fax: 1-602-249-4813 Phone: 1-602-242-4928. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Patty Baeza is available to help you. You can also file a civil rights complaint with the U.S. Department 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.

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