Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Master Miss

Address:
City:		State/ZipCode	CA AL AK AZ AR CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Master Miss

Copy Address From Above
Address

City	State	ZipCode
	CA AL AK AZ AR CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Vision

Insurance Information

Insurance Name:	None AARP Administrative Concepts Aetna Allegiance Allied Health American Family Insurance ARM, LTD ASSURANT HEALTH ASSURE BENEFIT ADMINISTRATORS BCBS Of Texas Benefit Admin System BENESIGHT BOON-CHAMPMAN BENEFIT ADMINISTRATORS Cap Rock Care First ChampVA - medical only Cigna Cigna-APWU Health Plan Cigna/Health Scope CLEAT - USE VSP, get policy holder SS Colonial Penn Constitution Life Insurance Coventry Health Care Employer Plan Services - Use VSP Eyemed FCE Benefits First Health GEHA Group and Pension Guardian - USE VSP, get policy holder SS Health Scope HealthSmart Preferred Care Humana Medical Humana Vision - Use Eyemed ITPE Liberty Mutual Workers Comp Claim Life Investors Insurance Company LOVELACE Mail Handlers Manhattan Life March Vision Medicaid Meritain Healthcare METLIFE - USE VSP, get policy holder SS Mutual Of Omaha MVP Health Care NALC New Vision Laser Center NM Lions Operation Kidsight No Insurance Novitas Solutions - Novitas Solutions OSCAR Physicians Health Choice Physicians Mutual Professional Benefit Admin Reserve National Senior Care Center SIERRA HEALTH Spectera Vision Standard Security Vision State Farm State Of New Mexico Human Services Department Superior Vision Texas Comptroller Tricare For Life Tricare West Triwest VA UHC Golden Rule UMR UNIFIED LIFE INSURANCE CO. UNITED AMERICAN United Health Care United Healthcare Shared Services United of Omaha Life Insurance UNIVERSAL HEALTH CARE USAA LIFE INSURANCE Vision Service Plan Wausau Benefits WebTPA Ysleta De Sur Pueblo Health and Human Services
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary

Insurance Information

Insurance Name:	None AARP Administrative Concepts Aetna Allegiance Allied Health American Family Insurance ARM, LTD ASSURANT HEALTH ASSURE BENEFIT ADMINISTRATORS BCBS Of Texas Benefit Admin System BENESIGHT BOON-CHAMPMAN BENEFIT ADMINISTRATORS Cap Rock Care First ChampVA - medical only Cigna Cigna-APWU Health Plan Cigna/Health Scope CLEAT - USE VSP, get policy holder SS Colonial Penn Constitution Life Insurance Coventry Health Care Employer Plan Services - Use VSP Eyemed FCE Benefits First Health GEHA Group and Pension Guardian - USE VSP, get policy holder SS Health Scope HealthSmart Preferred Care Humana Medical Humana Vision - Use Eyemed ITPE Liberty Mutual Workers Comp Claim Life Investors Insurance Company LOVELACE Mail Handlers Manhattan Life March Vision Medicaid Meritain Healthcare METLIFE - USE VSP, get policy holder SS Mutual Of Omaha MVP Health Care NALC New Vision Laser Center NM Lions Operation Kidsight No Insurance Novitas Solutions - Novitas Solutions OSCAR Physicians Health Choice Physicians Mutual Professional Benefit Admin Reserve National Senior Care Center SIERRA HEALTH Spectera Vision Standard Security Vision State Farm State Of New Mexico Human Services Department Superior Vision Texas Comptroller Tricare For Life Tricare West Triwest VA UHC Golden Rule UMR UNIFIED LIFE INSURANCE CO. UNITED AMERICAN United Health Care United Healthcare Shared Services United of Omaha Life Insurance UNIVERSAL HEALTH CARE USAA LIFE INSURANCE Vision Service Plan Wausau Benefits WebTPA Ysleta De Sur Pueblo Health and Human Services
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP Administrative Concepts Aetna Allegiance Allied Health American Family Insurance ARM, LTD ASSURANT HEALTH ASSURE BENEFIT ADMINISTRATORS BCBS Of Texas Benefit Admin System BENESIGHT BOON-CHAMPMAN BENEFIT ADMINISTRATORS Cap Rock Care First ChampVA - medical only Cigna Cigna-APWU Health Plan Cigna/Health Scope CLEAT - USE VSP, get policy holder SS Colonial Penn Constitution Life Insurance Coventry Health Care Employer Plan Services - Use VSP Eyemed FCE Benefits First Health GEHA Group and Pension Guardian - USE VSP, get policy holder SS Health Scope HealthSmart Preferred Care Humana Medical Humana Vision - Use Eyemed ITPE Liberty Mutual Workers Comp Claim Life Investors Insurance Company LOVELACE Mail Handlers Manhattan Life March Vision Medicaid Meritain Healthcare METLIFE - USE VSP, get policy holder SS Mutual Of Omaha MVP Health Care NALC New Vision Laser Center NM Lions Operation Kidsight No Insurance Novitas Solutions - Novitas Solutions OSCAR Physicians Health Choice Physicians Mutual Professional Benefit Admin Reserve National Senior Care Center SIERRA HEALTH Spectera Vision Standard Security Vision State Farm State Of New Mexico Human Services Department Superior Vision Texas Comptroller Tricare For Life Tricare West Triwest VA UHC Golden Rule UMR UNIFIED LIFE INSURANCE CO. UNITED AMERICAN United Health Care United Healthcare Shared Services United of Omaha Life Insurance UNIVERSAL HEALTH CARE USAA LIFE INSURANCE Vision Service Plan Wausau Benefits WebTPA Ysleta De Sur Pueblo Health and Human Services
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Primary Vision Concern	Blurry Vision Red Eye Eye Strain Burning Eye Pain Itching Sensitivity to Light Tearing Poor Night Vision Discharge Night Glare Dry Eye Double Vision Eye Infection Total loss of vision Eye Allergy Fluctuating Vision Flashes of Light Peripheral Vision Floaters Lazy crossed eyed
Secondary Vision Concern	Blurry Vision Red Eye Eye Strain Burning Eye Pain Itching Sensitivity to Light Tearing Poor Night Vision Discharge Night Glare Dry Eye Double Vision Eye Infection Total loss of vision Eye Allergy Fluctuating Vision Flashes of Light Peripheral Vision Floaters Lazy crossed eyed

Last Eye Exam

Last Eye Doctor

Family Medical History Unknown family history

Condition	Patient	Mother	Father	Sibling	No	Describe
Diabetes
Hypertension
Thyroid
CVD
Cancer

Pregnant/Nursing

No Unsure Pregnant Nursing Other

Last Physical Exam

Review Of Systems

Major Injury/Surgery	None --Abdominal-- appendectomy cholecystectomy gastric by-pass hernia repair lap band --ENT-- adenoidectomy sinus surgery tonsillectomy tympanostomy --Ortho-- broken ankle broken leg broken wrist carpal tunnel herniated discs hip replacement knee sx knee replacement shoulder sx --ObGyn-- C-section DandC hysterectomy lumpectomy mastectomy ovariectomy tubal ligation --Neuro-- brain aneurism brain hem brain tumor concussion spinal cord injury TBI --Thoracic-- abdominal aneurism aortic aneurism coronary bypass coronary stent hiatal hernia heart valve repair heart valve replacement pacemaker pacemaker/defribrillator --Urology-- prostatectomy vasectomy Other
Other MHx	None acid reflux acne rosacea Alzheimer's dz ankylosing spondylitis anxiety asthma atherosclerosis atrial fib autism benign prostatic hyperplasia bipolar carpal tunnel syndrome Celiac dz chronic fatigue cluster headaces congestive heart failure COPD Crohn's dz dementia depression diverticulitis Down syndrome eczema emphysema endometriosis epilepsy erectile dysfunction fibromayalgia gallstones GERD gonorrhea gout heart attack hepatitis herpes simplex HIV/AIDS hypercholesterolemia hyperlipidemia hypertriglyceridemia IBS insomnia kidney dz kidney stones migraine multiple sclerosis myasthenia gravis osteoarthritis Parkinson'd dz polycystic ovary syndrome psoriasis rheumatoid arthritis sarcoidosis schizophrenia shingles sinusitis sleep apnea systemic lupus (SLE) TB temporal arteritis vertigo Other
General	good fever fatigue loss of appetite weight gain weight loss Other
ENT	None chronic cough congestion daytime drowsiness dry mouth/throat gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea tinnitus toothache hypercholesterolemia Other
CVD	None chest pain hypertension cholesterol racing heartbeat shortness of breath swollen feet/ankles TIAs Other
Pulm	None asthma chronic cough cyanosis productive cough shortness of breath wheezing Other
Gen/Ur	None overactive bladder painful urination underactive bladder urgency in urination urinary incontinence Other
GI	None abdominal pain bloody stools constipation dark urine diarrhea gastric reflux (GERD) jaundice nausea vomiting Other
Endoc	None addison's disease adrenal gland disorder connective tissue disease cushing's disease gigantism graves disease growth hormone disease hashimoto thyroiditis lupus marfan syndrome myocarditis pituitary disease polycystic ovary syndrome polyendocrine syndrome polymyositis rheumatoid arthritis sjogren syndrome ---Hyperthyroid--- heat intolerance sweaty diarrhea mood swings palpitations weight loss decreased menstruation ---Hypothyroid--- cold intolerant fatigue depression hair loss heavy periods constipation dry skin ---Diabetes--- frequent urination thirst hunger dizziness sweating headache ---Adrenal--- chronic hypotension darkening of skin ---Reproductive--- menstrual changes changes in libido ED Other
Mus/Skel	None arthritis decreased range of motion gout joint pain muscle cramps pain/tenderness rheumatoid arthritis stiffness swelling weakness Other
Skin	None acne blisters cysts dandruff eczema erythema growths nodules psoriasis rash rosacea scales seborrheic / actinic keratosis ulcerations warts Other
Neuro	None alzheimer balance problems changes in senses dementia memory problems muscle weakness numbness/tingling personality changes schizophrenia speech problems tremors vertigo Other
Psych	None anxiety changes in eating habits changes in sex drive delusions depression excess anger excessive worrying frequent mood changes hallucinations insomnia obsessive/compulsive paranoia social withdrawal substance abuse suicidal violence Other
Hem/Lym	None aids anemia arthritis auto-immune disease hodgkin lymphoma lupus lymphoma rhematoid arthritis bleeding gums cuts slow to clot easy bruising heavy periods hx of significant blood loss jaundice nosebleeds pale skin pounding in ears rapid hearbeat shortness of breath Other
Immune	None asthma hiv hives itching mild allergy symptoms severe allergy symptoms redness sneezing swelling Other

Condition	Patient	Mother	Father	Sibling	No	Describe
Glaucoma
Macular Degeneration
RD/RT
Cataract
Amblyopia/Strabismus

Ocular Injury/Surgery/Lazer	None Anti-VEGF tx blepharoplasty corneal transplant cryo ECCE/IOL filtering procedure focal laser grid laser laser trabeculoplasty LASIK LPI peripheral retinal laser PRK PRK PRP ptosis repair RD repair RK scleral buckle SLT strab sx stromal puncture valve YAG cap Other
Other History	None choroidal nevus episcleritis chalazia frequent styes corneal ulcers GPC keratoconus Fuch's endothelial dystrophy uveitis Other
Rx/Over The Counter Drops	None Art Tears Oasis Tears Refresh Systane Blink Visine Restasis Xiidra Other

Medical Insurance
VCP
Marital Status	Annulled Divorced Domestic Partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Other
Referred By	Other
Occupation/Grade	student Other
Employer/School
Parent/Guardian
LiveAlone	assisted living No nursing home Yes Other
Smoking Status	Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other
Alcohol	None social occasional 1-2 drinks/day several drinks/day Other
Meds Sum No current medications	None Accupril / Quinapril Aciphex / rabeprazole Actonel / risedronate Actos Acyclovir Adderall Advair Diskus Albuterol Allegra / fexofenadine alprazolam Altace / ramipril Amaryl / glimepiride Ambien / zolpidem Amiodarone amlodipine amoxicillin Aricept / donepezil Arimidex / Anastrozole Atacand / candesartan atenolol Augmentin Avandia / rosiglitazone Avapro / irbesartan azithromycin BCP Buspar Captopril Carbamazepine Casodex / bicalutamide Celebrex Celexa / celecoxib Cialis Cipro / ciprofloxacin citalopram Clarinex / desloratadine Clonidin Combivent / albuterol-ipratropium Coreg / carvedilol Coumadin / warfarin Cozaar / losartan Crestor Depakote Detrol / tolterodine Diclofenac Dilantin Diovan / valsartan Ditropan XL / oxybutynin Effexor / venlafaxine Evista / raloxifene Exelon / rivastigmine Flomax / tamsulosin Flonase / fluticasone Flovent / fluticasone Fosamax / alendronate furosemide gabapentin Glucophage / metformin Glucotrol / Glipizide Glyburide HCTZ Humulin / insulin hydrocodone-acetaminophen Hydrocortisone Hyzaar losartan Lanoxin / digoxin Lantus / insulin Lasix Lescol / fluvastatin Levaquin / levofloxacin levothyroxine Levoxyl Lexapro / escitalopram Lipitor / atorvastatin lisinopril Lotensin / benazepril Lotril / amlodipine-benazepril metformin Methlyprednisolone metoprolol Mobic / meloxicam Monpril / fosinopril Nasacort Nasonex / mometasone Neurontin / gabapentin Nexium / esomeprazole Norvasc / amlodipine Novalog omeprazole Oxycodone Oxycontin / oxycodone Paxil / paroxetine Pepcid Plaquenil Plavix / clopidogrel Pletal / cilostazol Pravachol / pravastatin Prednisone Premarin / estrogen Prempro Prevacid / lansoprazole Prilosec / omeprazole Procar / finasteride Protonix / pantoprazole Proventil Prozac Risperdal / risperidone Ritalin Seroquel / quetiapine sertraline simvastatin Singulair / montelukast Synthroid / levothyroxine Tetracycline Topamax Toprol / metoprolol Tricor / fenofibrate Ultracet / tramadol-acetominophen Valium Viagra / sildenafil warfarin Wellbutrin / bupropion Xanax Zantac Zestril Zetia / ezetimibe Zithromax / azithromycin Zocor / simvastatin Zoloft / sertraline zolpidem Zyrtec Other
Allergy Sum No known drug allergies	Other
Vit/Supp	None Multi-vitamins Vit A Vit B Complex Vit B12 Vit C Vit D Vit E biotin Calcium Fe Mg Mn Zn Biotears Fish Oil Flax Evening Primrose oil Borage oil Glucosamine Chondroitin MSM niacin CoQ10 zeaxanthin Lutein iCaps Lutein & Omega 3 Macula Complete Ocuvite / I-caps Preservision AREDS 2 Preservision Ginko-Biloba resveratrol St John's wort Red Yeast Rice Juice+ curcumin garlic green tea extract probiotic Stinging nettle Other
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify White Other
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
Preferred Language	English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

COVID-19

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition	Yes	No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact
With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact
With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis,
Or Have You Been Asked To Quarantine?

Digital Retinal Image / Dilation

A DIGITAL IMAGE OF THE RETINA WILL BE DONE ANNUALLY FOR EVERY PATIENT

Retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments and diabetic retinopathy can now be seen without dilation for most patients and it is far easier for the doctor to examine the eye with the digital image instead of looking through the eye with a microscope which gives a very limited view. The time to evaluate the retina is instant. The exam is painless and allows a 200o view of the entire internal health of the eye without drops.

EARLY DETECTION IS CRUCIAL!!!
Without a thorough internal eye examination serious disease can be missed such as:

All of these can lead to vision loss, blindness or even DEATH.



The small fee is $29, and may be covered by your insurance company, if a medical condition is found.

"I understand the optos retinal imaging test is the standard of care at Eyeland Vision. This is a required test in order to give the doctors the information they need to give the best quality care for each patient.

Pupil dilation is an important component of every comprehensive eye examination. Along with the Optos, retinal photo, it provides the most adequate view of the inside of your eye and allows your doctor to rule out internal eye diseases, in addition to systemic health conditions.

Dilation involves administering a series of drops into your eyes followed by a waiting period of at least 15 minutes. The side effects include short term blurring of your near vision and increased sensitivity to lights causing some difficulty as it relates to vision while working and or/driving. Some patients find it difficult to drive after being dilated and bring a driver with them. These effects will last 4-6 hours.

I understand the importance and side effects of having my eyes dilated and I would like to:

Have my eyes dilated today Reschedule my dilation. There is no additional fee when you return for dilation. (Within 2 weeks) Not have my eyes dilated today , I understand that my refusal of dilation limits the doctor's ability to detect certain conditions.

Patient Signature Date

Signature / Submittal Tab

By checking the boxes below, you are providing a signature on file for Eyeland Vision and acknowledge that you have read and understand our office policies.

HIPAA (Privacy Act)

You have the right to expect your personal health information to be protected as outlined in the Notice of Privacy Practices. The terms of the notice may change. If you desire, a copy of the new Notice one will be provided to you by requesting one in writing from this practice. You can request to have your consent to use your Protected Health Information revoked at any time with assigned written request to this practice. By checking this box you agree that you have read and understand this form.

Patients Name Signature Date

Who may we discuss your medical information with or leave messages with regarding your care?

Patients Name Signature Date

Missed Appointments

Our doctors and staff designate a specific amount of time to each patient. Please call 24 hours in advance on weekdays and 48 hours in advance for Saturdays to change your appointment. A $25.00 charge for weekday and $50.00 for Saturday will be incurred if we do not hear from you before the designated time.

Insurance Agreement

Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company not Eyeland Vision. If your insurance company has not reimbursed our office in full within 60 days or in the event your insurance company denies benefits, you will be responsible for paying the charges.

For Contact Lens Wearers Only

Contact lens fit evaluation is necessary for new and existing contact lens prescriptions. This charge will be in addition to the comprehensive eye examination fee. Depending on the complexity of the prescription this fee may vary and may be covered by your current vision plan. Also please be aware that for the contact lens follow up fitting you may only return within 30 days of the initial fitting. This does not include additional contact lens material fees.

MEDICARE PATIENTS ONLY

The refraction (the part of the examination which measures your prescription for glasses), is not covered by Medicare and you would be responsible for paying the $40.00 refraction fee if performed.

TRICARE PATIENTS ONLY

If you are interested in a contact lens examination, please be advised this is a non-covered service by Tricare and you will be fully responsible for the contact lens examination. Based on the complexity of your prescription, the fee will be discussed with you prior to the examination.

By clicking the submit button below, I acknowledge that the information that I have inputted is correct and to the best of my knowledge. It will be updated to my medical records at Eyeland Vision. If I need a copy of my HIPAA rights and Eyeland Vision office policies, I will ask any of the staff members of Eyeland Vision for a hard copy.