Robert A. Kolarczyk, M.D.
  • Welcome
  • Our Practice
  • Meet the Doctor
  • Our Staff
  • Patient Forms
  • Our Services
  • Schedule an Appointment
  • Eye Care Articles
  • Check Your Benefits
  • Insurances Accepted
  • Optical Boutique
  • Locations

Download  your  forms

Patient Forms

Personal Registration Form
File Size: 54 kb
File Type: pdf
Download File

medical_questionnaire.pdf
File Size: 25 kb
File Type: pdf
Download File

Optical Questionnaire
File Size: 64 kb
File Type: pdf
Download File

HIPAA Signature Page
File Size: 24 kb
File Type: pdf
Download File

HIPAA Privacy Policy
File Size: 40 kb
File Type: pdf
Download File

For Your Convenience,

You can print and complete these patient registration forms at home before your appointment. Please note that the HIPAA Privacy Policy is informational only. You do not need to include this document with your registration forms. If you prefer, you may fax the completed forms to our office at (805) 569-1155.

Please bring the following with you at the time of your appointment:
  • Insurance Card(s)
  • All Pairs of Glasses You Use
  • Contact Lens Information (if you are a contact lens wearer)
  • Medication Listing - Include Name, Strength, Dosage and Instructions of Use
Picture
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Contact Us

Santa Barbara Location:                 Solvang Location:
    
1801 State Street, Suite C                         540 Alisal Road, Suite 2
Santa Barbara, CA  93101                         Solvang, CA  93463
Phone: (805) 569-1000                              (805) 688-1833
Fax:      (805) 569-1155                              (805) 569-1155

Click here for SB directions:

Click here for Solvang directions:


SB Ophthalmology Hours:                SB Optical Shop Hours:
Mon   8:30 am - 5:00 pm                                    8:30 am - 5:30 pm
Tue    8:30 am - 5:00 pm                                    8:30 am - 5:30 pm
Wed   8:30 am - 5:00 pm                                    8:30 am - 5:30 pm
Thu    8:30 am - 5:00 pm                                    8:30 am - 5:30 pm
Fri      8:30 am - 5:00 pm                                    8:30 am - 5:30 pm

Office Lunch Hour:                                             Optical Shop Lunch Hour:
12:00 pm - 1:30 pm                                            12:30 pm - 1:30 pm


Solvang Ophthalmology Hours:        Solvang Optical Shop Hours:
Tue    8:30 am - 5:00 pm                                         8:30 am - 5:00 pm
Wed   (Limited Day - Call for Hours)                      (Call for Wed Hours)

Office Lunch Hour:                                                 Optical Shop Lunch Hour:

12:00 pm - 1:30 pm                                                12:30 pm - 1:30 pm                                                   




  • Welcome
  • Our Practice
  • Meet the Doctor
  • Our Staff
  • Patient Forms
  • Our Services
  • Schedule an Appointment
  • Eye Care Articles
  • Check Your Benefits
  • Insurances Accepted
  • Optical Boutique
  • Locations