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Patient information

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Billing Information for Primary on Account

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Primary Vision


Primary Medical

Medical History

Personal Medical History

Do you have any of the following issues/conditions?

Personal Eye History

Family Medical History

No known family history of health issues

Does anyone in your family have any of the following issues/conditions?:

Family Eye History

No known family history of eye disease

Patient Acknowledgements
Signing this section is required of all patients before services are performed


The full Notices of Privacy Practices of Budaful Eyes, P.A. is available by request from our check-in desk.

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

  • Obtain payment from third-party payers.

  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I have read and understood the Notice of Privacy Practices of Budaful Eyes, P.A. I understand that I may request in writing how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Signature(Please type): Date:

  • I understand that payment for services is due in full at the time services are rendered.
For patients using insurance:
  • I understand that vision plans only provide coverage for routine eye examinations and discounts on glasses and contacts. I also understand that vision plans do not cover for any medical eye problems that I am having.

  • I understand that my medical insurance will be billed today if I am having any medical eye problem as determined by the doctor, and that I am responsible for any and all deductibles, copayments, and coinsurance amounts under the terms of my medical plan.

Signature(Please type): Date:


Contact lenses are FDA regulated medical devices. Contact lens professional fees cover the additional testing taken to properly evaluate and fit your contact lenses for optimal health and clarity.

The contact lens fitting fees are as follows:

•Single vision, non-astigmatism: $75.00
•Single vision, astigmatism: $100.00
•Multifocal or monovision: $125.00
•Specialty Contact Lens Fittings: $150.00 & up
•Training for 1st time wearers: $15.00

Fitting fees cover prescription trial lenses and 60 days of follow-up care. If you return beyond the initial 60 day period, an additional visit may be charged ($50). Fitting fees do not cover the cost of contact lens supplies and cannot be refunded.
I have read and understood the above information and acknowledge that any fees not covered by my insurance will be my responsibility and must be paid at the time of service.

Signature(Please type): Date:


  • In order to provide comprehensive quality eye care, all routine exams will require mandatory Optomap retinal imaging. These images assist in the detection of retinal diseases and other eye conditions. These scans are an additional $39 in the event that they are not covered by your insurance.
    (Note: This service is covered if you are paying out-of-pocket.)

  • A patient is considered late when they arrive after their scheduled appointment time. We will try to work you into the next available time, but other patients who have arrived on time for their appointments may see the provider first.

  • If you cannot keep your appointment, please call us at least 24 hours. Patients that miss two consecutive appointments will be charged a $50 no-show fee and the fee must be paid before another appointment can be made. Please keep in mind that three missed appointments may be cause for discharging a patient from the practice.

  • Unpredictable situations may occur with patients who require extra attention during the course of the day. We appreciate your understanding when there are delays and the same courtesy will be extended to you if you have additional needs.