Patient information

*This field is required

*This field is required

*This field is required

Billing information

If yes, please provide the billing address information below

Primary Vision Insurance

Primary Medical Insurance

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

Contact Lens Wearers only:

Medical History:

Do you have any of these medical conditions?

Family Medical History

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

Family Eye History

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

Review Of Systems

Social History

Policies, Consent, Submit Data


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

Condition Yes No
Shortness Of Breath Or Difficulty Breathing
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?

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Notice of Privacy Practices

View Notice of Privacy Practices Form

Patient Responsibility

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both:

-Vision care plans: such as VSP and EyeMed
-Medical insurance: such as Blue Cross/Blue Shield and Medicare

Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract. For glasses orders, once your order is finalized, full payment of the glasses is expected at the time of service. Once the order is submitted to the lab, lens changes and refunds are not allowed. Thank you for allowing us to serve your eye care needs.

I have read and agree with these policies.

Reviewed HIPAA Notice of Privacy Practices:

Optomap or Eye Dilation

As part of a comprehensive eye examination, it is recommended that ALL patients have the internal health of their eyes thoroughly evaluated. This is performed either as a dilated retinal exam or with the Optomap Retinal Imaging camera. Dilation of pupils with eye drops is still considered the most complete way of viewing the retina.

Our physicians are committed to discovering and documenting eye problems such as macular degeneration, diabetic retinopathy, glaucoma, retinal holes, or detachments (all of which can lead to partial loss of vision or blindness). Systemic diseases such as high blood pressure and diabetes can also be discovered during the retinal exam. Due to a limited view of the internal structures of the eye, these health conditions are difficult to detect (and potentially treat) without the Optomap Retinal Imaging camera or dilation of the pupils.

• Provides a digital eye wellness scan to detect the presence of disease.
• It allows your doctor to review your Optomap Retinal Image with you.
• Provides an annual, permanent record for future review and comparisons.
• Gives an in-depth view of the retinal layers (where disease can start).
• It is fast, easy, and comfortable.
• Will NOT require dilating drop (drop would result in light sensitivity and blurred vision for 4-6 hours).

Some patients may need to have their eyes dilated in combination with Optomap Retinal Imaging; this is dependent on what your doctor determines is best for your eyes. (Example: You will need to be dilated if you are coming for evaluation of cataracts, floaters, flashes of light, or other eye disorders better assessed with dilation). PLEASE NOTE: THERE IS AN ADDITIONAL CHARGE OF $40.00* THAT WILL NEED TO BE COLLECTED ON THE DATE OF SERVICE. OPTOMAP RETINAL IMAGING IS NOT COVERED BY MOST INSURANCES.

I have read and understood the above, and