Phone: (985) 641 - 9900 / (504) 486 - 5353   Fax: (985) 641 - 4406

Rudolph M. Franklin, M.D.  

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Retinal Diseases and Uveitis
     

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           To schedule an appointment, you may call (985) 641 - 9900 / (504) 486 - 5353 or complete our online appointment request form.

         As a new patient, we ask that you first provide us with a detailed medical history by filling out the medical history form (located below).  It is important for us to know your complete eye history, including laser procedures, eye surgery, and eye medications, as well as any other general medications you may be taking for non-eye related problems. 

         Having all the medical forms filled out before your appointment will make the overall process faster.  Please print and fill out all medical forms located below.

Patient Information Sheet
   

Health History Form
   

Paient Authorization/Release
   

Notice of Privacy Pracices (HIPPA)
   

HIPPA Acknowledgment Form
   

 

 

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