Online Patient Form

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

Patient Information


Title First Last MI Suffix Nickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Preferred Contact Method:
Cell Phone: Email
SSN Occupation
Birthday Employment Status
Sex Employer / School Name
Marital Status Misc/Guardian
Who may we thank for your referral?:

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:

Medications: No Meds Used Over The Counter Medications:
Vitamins: Drug Allergies: No Known 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

Do you or anyone in your family have history of the following:

Unknown family history

Diabetes Describe:
High Blood Pressure Describe:
High Cholesterol Describe:
Thyroid Describe:
Cardiovascular Describe:
Cancer Describe:

Eye History

Do you currently have any of these symptoms/conditions?:
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

Glaucoma Describe:
Cataracts Describe:
Macular Degen Describe:
Retinal Detach Describe:
Cross/Lazy Eye Describe:

Medical Issues

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




Anything not listed? Please describe:

Social History

Hobbies: STD's:

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

Race: Ethnicity: Preferred Language:

Policies and Submit: This Is Important Information For You!

Revised June 1, 2020


  1. Our offices have implemented a $50 cancellation/no-show fee. Any cancellations 24 business hours or less before their appointment time, or a no-show for any reason, a $50 fee will be charged. Please be respectful of other patient's time by being at our office at the agreed time we reserved for you, having insurance information in advance to us, and paperwork completed.

  2. All payments are required at the time services are rendered. If we are in network with your contracted insurance, your co-pay and cost of products ordered must be paid on the date of service. This includes medical or vision plan specialist co-pay, $44 for Optomap, contact lens evaluation (range is $90-160, depending on Rx) and materials purchased or ordered. Federal Law requires that we collect co-pays at the time of service, otherwise we can be charged with fraudulent business practices. If your deductible has not been met, payment will be due in full at the time of appointment. We will give a Private Pay discount.

  3. It is the patient's responsibility to know whether or not the provider of service(s) is in network. It is also the patient's responsibility to know what benefits their medical insurance provides along with deductible amounts that need to be met. The agreement with your medical insurance company is a contract between you and your insurance company; Bee Cave Vision Center/Dripping Springs Vision Center files your claim with your insurance as a courtesy to you, the patient. However, we MUST be provided with medical insurance PRIOR to your appointment. If the patient does not know who their insurance provider is by the time of their exam, the patient is responsible for all charges. Patient will be given a private pay discount, provided a receipt with diagnosis to file for possible reimbursement. Discounted Private Pay fees are as follows: $199 for a New Patient exam, $178 for an Established (if last exam was within 2 years here) exam.

  4. I, the patient consent to medical treatment and/or a full comprehensive exam provided by Bee Cave Vision Center/Dripping Springs Vision Center. I also consent to release of medical records to my medical insurance and vision plan provider to ensure claim submission on my behalf. Per HIPAA, I understand my records are protected and will not be released to anyone other than my insurance company, or person specified by written request by me. The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

  5. We accept VSP vision plan for material allowances (glasses and contact lenses). BCVC/DSVC MUST be given VSP information on or prior to the date of purchase in order to obtain an authorization and file a claim on your behalf for materials. We will provide a detailed receipt if patient discovers coverage after the date of purchase to submit for possible reimbursement.

  6. All contact lens follow up appointments during the 30-day period following the initial exam are at no cost to the patient. However, after 30 days, patients are charged on a per visit basis for the office visit.

  7. Bee Cave Vision Center/Dripping Springs Vision Center is happy to special order a frame for you. We require a fifty percent deposit that is non-refundable. If you decide that you do not want the frame once it comes in, you can apply that deposit to any other materials in office.

  8. Bee Cave Vision Center/Dripping Springs Vision Center has a 30-day adjustment period to your new prescription. Dr. Dobson recommends wearing your new eyewear for approximately two weeks to allow for adaption to your new prescription. Within 30 days, if you are unable to adapt to your new prescription, we will remake your lenses with a different lens option. There will be a 50% restocking fee for any refunds granted.

  9. The following are the insurance plans we accept for exams: Aetna, Blue Cross Blue Shield, Cigna, Humana, Medicare, United Healthcare. We accept VSP for glasses and contact lens materials.

  10. For any balances on your account, you will receive a statement requesting payment. This balance is due upon receipt. Failure to pay an outstanding balance will result in sending your account to a Collection Agency. You will also be responsible for attorney's fee associated with collecting funds from you. If you have a question about your bill, please contact your insurance company for explanation. If you have further questions, you may call our billing department at 512 804-2020.

  11. Please be aware that there is a $35.00 fee for returned checks.

By clicking the submit button below, you acknowledge that you have read and agreed to our policies. You may ask for a copy of these policies at any time.

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