Online Patient Forms

Patient information

Title

First name

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Last name

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Nickname

Address

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City

State

Zip Code

Home Phone

Cell Phone

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Work Phone

Other Phone

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Preferred Contact Method

Birthday

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SSN

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Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Gender

Male Female

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes or No

Title

First

Last

Middle

Suffix

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Medical Insurance

*HMO plans are not accepted
*We are currently not accepting new patients with vision insurance. If you are an existing patient please call the office to coordinate your benefits. Thank you!

Insurance Information

Insurance Name:

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Insurance ID:

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Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured: Spouse Child Other

Sex: Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

Please choose from the menu options

Eye History

What is the reason for your visit?

Please describe your visual needs. Glasses, Contacts.

How did you find us?

What is your Occupation?

Who is your Primary Care Physician?

Pharmacy of choice?

Do you have a history of seizures?

Are any of your family already patients at SeePort Optometry? If so please list.

When was your last eye exam

On average, how many hours per day are you using a computer?

How far away is your computer screen from your eyes?

Are you interested in Safety Sunglasses?

Are you interested in Computer Progressive Eyeglasses?

Are you interested in LASIK?
YES

Are you interested in Contact Lenses?

Have you ever had Contacts? If so, what kind, and do you wear monthly, daily, bi-weekly, or other?

Do you have back up glasses for your contacts?

Do you have seasonal allergies?

Have you had glare/halos affect your vision?

Do your eyes get sandy, scratchy, gritty or dry?

Do you rub your eyes?

Have you experienced any Flashes of Light in your vision recently?

Are you Pregnant Or Nursing?

Are you Diabetic?

If yes, for how long?

Average blood sugar

Last A1C

Medical history

Do you currently have any of these eye symptoms?

Do you currently take any eye drops including artifical tears?

Please list all Medicines/Vitamins that you currently take:

Please list all Medical/Drug Allergies you have had:

Please list all major Injuries, Surgeries, Hospitalizations you have had:

Review Of Systems

*Check all that apply

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Family History

Does Anyone In Your Family Have/Had Glaucoma, Retinal Detachment, Macula degeneration, Crossed/Lazy eyes, Blindness, Cataracts, Other eye diseases

Does anyone in your family have/had Diabetes, High Blood Pressure, Heart Disease, Cancer, Athritis, Lupus, Kidney Disease, Thyroid, Other

Social History

Do you use tobacco products?

If yes, type/amount/how long?

Do you drink alcohol?

If yes, type/amount/how long?

Do you use recreational drugs?

If yes, type/amount/how long?

Have you ever been exposed to or infected with HIV, Hepatitis, Gonorrhea, Syphilis, Herpes? If so please list.

Our Doctor routinely performs dialated eye exams to allow evaluation of the internal health of your eyes. Doing this may cause blurred vision and sensitivity to light for several hours, so you should NOT drive untill dilation has worn off.
*This field is required

COVID-19

If you are having any symptoms of being sick, please reschedule your appointment or speak to a staff member.

Office Policies/Financial Agreement

OUR MISSION: To strengthen our community by enhancing our citizen's sight and improving their total health by delivering personal care.

OUR PROMISE: As your trusted eye care professionals, our promise is to always recommend and offer to you our coveted patients the best medical treatments and options available despite the uncertainty of the insurance marketplace and coverages they may offer.

WELCOME: If you are a new patient to us or even returning patients who desire to be fit with eyeglasses or contact lenses, please be prepared for your visit to take 1 to 2 hours on average depending on your needs. We do our utmost to respect each individual's time, however we practice personalized health care and unexpected problems occur that occasionally will interrupt our schedule which could possibly cause you delays. Please accept our sincere apologies if you get delayed. Please help us by allotting appropriate time in your schedule and communicating to us anytime constraints you may have, so we may effectively serve your individual needs. If delays occur please discuss with us any time limitations you have, so we can expedite your visit or reschedule your appointment if necessary.

CANCELLATION/MISSED APPOINTMENT POLICY: Please kindly give us 48 hour notice if you cannot make your appointment. We have set aside time to meet your needs at your appointed time and therefore we have made that time unavailable to others. It is important to us to help as many patients as possible in meeting our mission to strengthen our community. We consider 15 minutes after your appointed time to be a missed appointment. If you truly have an emergency arise that will prevent you from making your appointment, please alert us as soon as possible. We have adopted the following policy for all other missed appointments: First missed appointment will result in a reminder and review of this policy. Second and all future missed appointments will result in a $50 fee to cover administrative costs. This fee cannot be covered by insurance. Thank you for your cooperation.

SERVICES: Medical eye care services vary widely based on the services performed. These services may incur additional costs to your vision exam or may change a vision exam to a medical exam as we determine what services are necessary for your situation. The total cost of your exam may not be known until the conclusion of the exam. Examples of medical services include but are not limited to management of cataract, glaucoma, floaters/flashes, ocular allergies, dry-eye syndrome, diabetic ocular complications and foreign body removal.

Vision exams are for those seeking eyeglasses or contacts. A contact lens fitting is additional and can vary depending on the type of lenses and amount of service required for a successful fit. An exam is often required to determine the type of fit necessary. It is noteworthy, most vision plans will not cover both glasses and contact lenses or fitting fees.

Refraction is the portion of the eye exam that allows the Doctor to determine your need for vision correction and is necessary for a glasses or contact lens prescription. Vision insurance benefits routinely cover this service as part of a vision exam, however Medical insurance does not and will typically incur an additional fee to you.

Do you want to be checked for a new eye glasses prescription?(May create a $65 charge with using medical insurance only.)

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Initials:

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FINANCIAL: To best serve you, it is necessary for you to provide any and all benefits prior to your examination. This includes Medical and/or Vision Insurance benefits and any discounts or certificates you wish to apply. Further, we ask that you advise us prior to examination of your desire to use a given plan or benefit. We do our best to inform you of your benefits and assist you in applying them. However, IT IS YOUR RESPONSIBILITY TO KNOW YOUR INSURANCE BENEFITS AND REQUIREMENTS INCLUDING IF YOUR BENEFITS REQUIRE A PRIOR REFERRAL OR PRE-AUTHORIZATION. YOU MUST PROVIDE/FACILITATE REFERRALS FROM YOUR PRIMARY DOCTOR OR CONFIRM WE HAVE SECURED REFERRALS AND/OR PRE-AUTHORIZATIONS 2 BUSINESS DAYS PRIOR TO YOUR APPOINTMENT OR THE COST OF SUCH SERVICES MAY BECOME YOUR RESPONSIBILITY. If you have questions or need to know more about your benefits please discuss your concerns with us prior to being seen by the Doctor. I understand and agree.
However, IT IS YOUR RESPONSIBILITY TO KNOW YOUR INSURANCE BENEFITS AND REQUIREMENTS INCLUDING IF YOUR BENEFITS REQUIRE A PRIOR REFERRAL OR PRE-AUTHORIZATION. YOU MUST PROVIDE/FACILITATE REFERRALS FROM YOUR PRIMARY DOCTOR OR CONFIRM WE HAVE SECURED REFERRALS AND/OR PRE-AUTHORIZATIONS 2 BUSINESS DAYS PRIOR TO YOUR APPOINTMENT OR THECOST OF SUCH SERVICES MAY BECOME YOUR RESPONSIBILITY.
If you have questions or need to know more about your benefits please discuss your concerns with us prior to being seen by the Doctor. I understand and agree.

Initials:

*This field is required

I have read the above policy regarding payment for services rendered or products provided. Further, I understand that if insurance is being filed on my behalf, I will be responsible for co-pays, co-insurance, deductibles, and any other fees my insurance may not cover. Payment is expected at the time of service unless prior arrangements are made. If you have questions, please discuss with staff prior to your evaluation.

Initials:

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I agree to pay any and all fees accrued from collection companies if my overdue balance should be sent to such company. Unpaid bills will be sent to a collection company after 90days from the date of service unless prior arrangements are made. I understand that collection fees may be as much as 33% of my total overdue bill.

Initials:

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I hereby authorize payment directly to the Doctor for benefits otherwise payable to me for services as coded for the exam and/or materials. I understand that I am responsible for the balance of fees not covered by insurance. Note: any refunds I am due will be made via check and may require several weeks to process and receive.

Initials:

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ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

*One selection below is required

The law requires that Jesse S Hicks, OD, PA/SeePort Optometry make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that

I have read or had explained to me prior to any services offered Jesse S Hicks, OD, PA's Notice of Privacy Practice and agree to continue my care with Jesse S Hicks, OD, PA under said terms.

I was given to opportunity to read Jesse S Hicks, OD, PA's Notice of Privacy Practices and declined but wish to continue my care with Jesse S Hicks, OD, PA under the terms of Jesse S Hicks, OD, PA's privacy policies.

I have read or had explained to me prior to any services offered Jesse S Hicks, OD, PA's Notice of Privacy Practice and do not wish to continue my care with Jesse S Hicks, OD, PA under said terms.

The Notice of Privacy Practice could not be read due to the emergent nature of the care or other reason described as.

* Please choose 1 option

I am the patient being examined today
I am a parent/guardian/power of attorney of the patient.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
Signature

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Date

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If you are signing as a personal representative of the patient, please indicate your relationship

AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION

I authorize Jesse S Hicks, OD, PA/SeePort Optometry to release health information identifying me (including, if applicable, information about substance abuse, mental health conditions, genetic information, and HIV infection or AIDS) under the following conditions

Specific information to be released:
All Appointment information Eyeware Pickup Testing Results Billing Information None

Name and address of the Recipient(s):
Recipient 1: Recipient 2:

Termination date for authorization:
None
Termination date:

*This field is required

It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices. When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
Signature

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Date

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If you are signing as a personal representative of the patient, please indicate your relationship

SPECTRALIS OCT Informed Consent

SeePort Optometry is proud to provide our patients with the most highly advanced technology available in retinal screening! Our ability to view your internal retinal health is now dramatically improved with Spectralis OCT (Optical Coherence Tomography). Dr. Hicks is concerned about problems such as macular degeneration, glaucoma, macular holes/edema, macular pucker or epiretinal membranes, and diabetic retinopathy; all of which could lead to partial loss of vision or blindness.

EARLY DETECTION IS CRUCIAL

Spectralis OCT Provides:
• A set of annual eye wellness retinal scans for the macula and for glaucoma
• An in-depth view of the retinal layers (where disease usually starts)
• The ability to show you your images today during your exam
• A permanent record for your medical file, which gives your doctor comparisons for tracking and diagnosing potential eye disease

The $39 charge, which would be due at the time of your exam, is typically not covered by your medical or vision insurance unless being used to actively follow disease. Dr. Hicks would like for ALL patients to have a Spectralis OCT screening annually.

Advanced Glaucoma Screening

Normal Retina with thick donut shaped neurons

Glaucoma causes atrophy of the Retina or thinning due to lost neurons

Please check one of the following:

YES: I understand the importance of having the SPECTRALIS OCT Retinal Screening and would like to have it reviewed by the doctor ($39 copay).
NOT SURE: I understand that the doctor would like for me to have these images taken, please provide me further information.
NO: I decline the advanced screening at this time.

Patient Signature: Date: