Online Patient Form

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After completing all the forms, please submit your data using the botton at the bottom of the page. Thank you!

Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Primary Doctor Misc/Guardian

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary Medical Insurance

Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical

Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Vision Insurance

Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Reason for Visit: Secondary Reasons:

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot:

Family Medical History



Diabetes: Type: Year Diagnosed: HbA1C:
High Blood Pressure: Describe:
High Cholesterol: Describe:
Thyroid Disease: Describe:
Heart Problems: Describe:
Cancer: Describe:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time: Days per week worn: Hours per day worn:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

Hobbies: STD's:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:

Office Policies and Practices

Financial Responsibility

As a courtesy to you, we will submit the billing for today’s services to your insurance carrier if we are a participating provider for that plan. Any balance not paid by your insurance carrier is your responsibility, and you will receive a statement for payment. Unless prior arrangements are made, full payment is due at the time of service. For your convenience, we accept Discover, MasterCard, Visa, American Express, and CareCredit. Co-payments will be collected at the time of your appointment. I understand that payment is due at the time services are rendered, all sales are final and no refunds are given. For delinquent accounts, I agree to be responsible for any reasonable collection fees incurred by Iconic Eye Care to collect payment for materials and/or service rendered.

Dilation Consent

Dilating the pupils with eye drops allows the optometrist to obtain a better view inside your eye to ensure optimal eye health. Health problems such as glaucoma, macular degeneration, and diabetes can be better observed with dilation. Pupil dilation may result in mild blurred vision when reading and light sensitivity for up to 4 hours.

Consent for Use and Disclosure of Health Information

I understand that the privacy practices of Iconic Eye Care are in compliance with the Health Insurance Portability and Accountability Act (HIPAA). I acknowledge that I may request a copy of this Act from the front office staff. I have had full opportunity to read and consider the contents of the Consent form and Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to Iconic Eye Care use and disclosure of my protected health information to carry out treatment, referrals, payment activities, and health care operations. We may disclose your health information to an optician, ophthalmologist, or other health care provider providing you treatment. Insurance claim information is transmitted via a secure Internet connection. Iconic Eye Care may also send me text messages and email correspondence, such as recall notices.

Advanced Beneficiary Notice (ABN)

Your insurance does not pay for all care, even some care that you and your vision care provider have good reason to think you need. Your insurance will not pay for the screening retinal photographs; our fee for retinal photographs is $39. The screening retinal photographs provide the doctor with an in depth view of the central retina and provides a permanent record to compare and track potential eye diseases. The doctor highly recommends the screening retinal photographs, for every patient, as an important part of your year eye exam.

Contact Lens Patient Agreement

Please be aware that the evaluation and management of contact lenses is performed in addition to your eye exam and there is a separate fee for this service. This service must be performed within 3 months of your comprehensive exam or an additional refraction and contact lens evaluation fee will apply. The evaluation and management fee is based on the type of contact lenses prescribed and the complexity of the evaluation and management process. A 45 day trial period, which will provide you with two follow up visits, is included. An additional fee may occur if the reason for the delay of treatment is not the fault of Iconic Eye Care or contact lens backorder. Contact lens evaluation may not be covered by insurance.

By signing below, I agree to the offices policies and practices.

Signature: Date:

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