Patient Registration Form

Please provide a telephone number, with area code, so we can contact you.

Please check off any current conditions you suffer from

Do you have trouble adapting to darkness?​​​​​​​

Do you wear glasses?​​​​​​​

Do you wear contact lenses?​​​​​​​

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take, your dosage(s), and what conditions you are taking the medication for.

Please list all drug allergies you have

​​​​​​​Please check off any current conditions you suffer from:

Insurance Company Name

Do you have secondary insurance?

If you have any comments you would like to add, please enter them here.

Health Information Protection

Signature of Patient or Representative

FINANCIAL AGREEMENT STATEMENT

ROUTINE/MEDICAL/GENERAL POLICIES

1. A copy of your insurance card(s) must be presented at time of service.

2. Payment of your copay, co-insurance or deductible is due at the time of service.

3. Eye exam, refraction and contact lens fit fees are due at the time of service and are non-refundable.

4. All routine/yearly exams require a refraction to be performed as part of your visit. If we are billing your exam thru your medical insurance due to a medical diagnosis, we are required to collect the $30 fee in addition to your co-pay as this is not paid by any medical plan.

5. Any referrals required by your insurance from your primary care doctor are due at the time of service. If you do not have one your appointment will need to be rescheduled.

6. We accept cash, personal check, Care Credit and all major credit cards.

7. There is a $35 non-refundable fee for any check returned from your bank.

8. Balance bill payments are due within 30 days of payment from your insurance company.

9. There is a $25 late fee assessed to any open balances after 90 days.

10. Failure to show up for or to give at least a 24 hour notice that you will not be coming for your appointment may result in a $30 no show/cancellation fee that must be paid before booking any future appointments.

11. There is a $25 non-refundable per form fee to fill out forms. Forms could include, but are not limited to, any insurance, FMLA, Worker’s Comp or other forms. This fee is due, plus postage if needing to be mailed, prior to filling out/mailing/faxing forms.
    
    

OPTICAL & CONTACT LENS POLICIES

1. Eyeglasses and contact lens payments are due at the time of order.

2. No refunds will be given on eyeglass orders once they have begun processing at the lab or after dispensing. Any changes made may be subject to restocking fees. However, every effort will be made to address any concerns you may have.

3. Any non-prescription materials (sunglasses, specialty computer glasses or readers) are returnable only for store credit within 7 calendar days under the condition they meet practice resale standards.

4. All new and previous contact lens wearers will be charged a non-refundable annual contact lens evaluation fee, which ranges from $60 - $120+, or the amount dictated by your insurance company. This fee is in addition to the eye exam fee and is due at the time of service. This fee must be paid in order to issue a new/valid prescription for ordering purposes.

By signing you agree that you have read and you agree to all of the terms listed above. By signing you also agree to be financially responsible for any and all of the charges incurred by you and not paid for by your insurance plan. You also agree that if for any reason your insurance company denies payment on services or materials that you are responsible for payment in full.

​​​​​​​If you have any questions regarding this policy or your visit, please ask to speak with the Practice Administrator prior to signing.

Patient's Name

Date: