Online Patient Forms

Patient information

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Patient History


Eye History

Contact Lens Wearers only:

Medical History:

Do you have any of the following issues/ conditions?

Family Medical History

Does anyone in your family have any of the following issues/ conditions?

Family Eye History

Does anyone in your family have any of these eye conditions?

Social History

Patient Signatures

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

The full Notices of Privacy Practices of Eye Capitol, P.A. is available by request from our check-in desk, and is also available online at www.eyecapitol.com

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

  • Obtain payment from third-party payers.

  • Conduct normal healthcare operations such as quality assessments and physician certifications.


    • I have read and understood the Notice of Privacy Practices of Eye Capitol, P.A., which contain a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of privacy Practices at any time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

    I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

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    Signing this section is REQUIRED of all patients before services or treatments are performed

  • I understand that payment for services is due in full at the time services are rendered.

  • If ordering glasses or contact lenses, the full payment is expected at the time of ordering.


    • For patients using insurance:

  • I request that payment from my third-party insurer be made to Eye Capitol for any services or products furnished to me by this provider.

  • I authorize Eye Capitol to release any personal or medical information to any medical insurance, vision plan company, or its agents that is necessary for determining my benefits or collecting payment for services rendered.

  • I understand that I am responsible for any copays, deductibles, and co-insurance amounts after services have been rendered today or materials not covered by my insurance. It is ultimately my responsibility to know my insurance benefits and coverage.

  • I understand that Eye Capitol will act as my agent in filing my insurance. However, if payment is not received after a reasonable attempt at collecting from my insurance carrier, then I am ultimately responsible for any charges not covered by my insurance company.

  • I understand that vision plans only provide coverage for routine eye examinations and discounts on glasses and contacts. I also understand that vision plans do not cover for any medical eye problems that I am having.

  • I understand that my medical insurance will be billed today if I am having any medical eye problem as determined by the doctor, and that I am responsible for any and all deductibles, copayments, and coinsurance amounts under the terms of my medical plan.

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    CONTACT LENS AND CORNEAL HEALTH EVALUATION


    Single vision sphere (non-astigmatism):         $75.00
    Single vision astigmatism:                              $100.00
    Multifocal or monovision (presbyopia):          $120.00
    Specialty Contact Lens Fittings:                      $250 & UP
    These would include: (Keratoconus contacts, Gas permeable lenses, Scleral contact lenses)
    Training for 1st time contact lens wearers:    $35.00


    Biomicroscopy: An ocular microscope is used to examine the fit of the contact lenses and the health of the cornea.
    Corneal Topography: A digital mapping of your cornea to screen for disease and to monitor for undesirable changes caused by contact lens wear.
    Contact Lens Refraction: Prescription measurements are taken which are different than those for eyeglasses.


  • Fitting fees cover trial lenses and 30 days of follow-up care. Additional visits beyond 30 days incur a $50 fee per visit. Returning after 6 months of initial exam requires an updated complete eye exam and fitting fee.
  • Fitting fees are non-refundable and do not include contact lens materials
  • Medical treatment for issues found during your exam are billed to your medical insurance and you are responsible for any copays and deductibles at the time of service.
  • Contact lens services may not be covered by insurance, but some vision plans offer an annual allowance for contact lenses or related fees. Our staff will assist in maximizing your insurance benefits.
  • If you do not receive a contact lens fitting during your routine exam, you have up to two months from the date of your exam to have a contact lens fitting.

    • I have read and understand the above information and acknowledge that any fees not covered by my insurance will be my responsibility and must be paid at the time of service.

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  • Please arrive 15 minutes before your appointment. This allows us to complete or update your patient information and ensures that you will receive the fully allotted time for your appointment.

  • A patient is considered late when they arrive after their scheduled appointment time. If you arrive late for your appointment, we will try to work you into the next available time, but other patients who have arrived on time for their appointments may see the provider first.

  • Please note that there is a $50 fee for missed appointments or for those cancelled within 24 hours of their scheduled time.

  • We strive to provide excellent customer service and accommodate your needs in a timely fashion. Unpredictable situations may occur with patients who require extra attention during the course of the day. We appreciate your understanding when there are delays. The same courtesy will be extended to you when you have additional needs.