Online Patient Form

Click here to return to the the previous website.

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

Patient Information


FirstLastMINickname
Address:
City: State: Zip Code:
Cell Phone:
Preferred Contact Method:
SSN Email
Birthday
Sex
Guardian (if patient is a minor)

Billing Information

Is The Billing Address the Same?
FirstLastMI
Address:
City: State: Zip Code:

Primary Vision

Insurance Information
Insurance Name:
Insurance ID:
Same as Patient
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:

Primary Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Same as Patient
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:

Medical History

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

Personal Medical History

Reason for Visit:

Over The Counter Medications:

Primary Care Physician:
Pregnant Or Nursing:


Interested in contact lens evaluation?: Interested in LASIK?:


Do you have any of the following issues/conditions?:

Family Medical History

Unknown family history

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

Eye History

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

Primary Vision Correction:
Want new glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Disposal:
Wear Time:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:

Review of Systems

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

Social History

STD's:

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


Patient Acknowledgements

Signing this section is REQUIRED of all patients before services or treatments are performed

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

The full Notices of Privacy Practices of Budaful Eyes, P.A. is available by request from our check-in desk, and is also available online at www.eyecapitol.com

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., which contain a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of privacy Practices at any time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict 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: Date:



FINANCIAL ACKNOWLEDGMENT

  • I understand that payment for services is due in full at the time services are rendered.

  • If ordering glasses or contact lenses, the full payment is expected at the time of ordering.


For patients using insurance:

  • I request that payment from my third-party insurer be made to Budaful Eyes for any services or products furnished to me by this provider.

  • I authorize Budaful Eyes to release any personal or medical information to any medical insurance, vision plan company, or its agents that is necessary for determining my benefits or collecting payment for services rendered.

  • I understand that I am responsible for any copays, deductibles, and co-insurance amounts after services have been rendered today or materials not covered by my insurance. It is ultimately my responsibility to know my insurance benefits and coverage.

  • I understand that Budaful Eyes will act as my agent in filing my insurance. However, if payment is not received after a reasonable attempt at collecting from my insurance carrier, then I am ultimately responsible for any charges not covered by my insurance company.

  • 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: Date:



OPTOMAP & DILATION FORM

In order to maximize efficiency and prevent the spread of COVID-19, the Optomap (a digital image of the retina) will be required of all patients unless a waiver is signed. The fee is only $39 and is not usually covered by insurance. (The Optomap is included for patients paying out-of-pocket.)

These images assist in the detection of retinal diseases, detachments, tumors, and other eye conditions. It is especially important for those with a history of diabetes, high blood pressure, flashes of lights, or a strong glasses prescription. These images also provide an excellent baseline for future comparisons.

I elect to have the Optomap retinal scan for an additional $39 fee.

I am declining to have retinal health evaluated with the Optomap imaging at this time*

Signature: Date:



CONTACT LENS EVALUATION (For patients interested in contact lenses)

Contact lenses are FDA regulated medical devices. Therefore, additional tests are performed to make sure your eyes are healthy enough to wear contact lenses, as well as ensuring that they fit property for optimal health and clarity. Contact lens professional fees cover the additional testing and chair time taken by the staff and doctor to properly evaluate and fit your contact lenses. Note: Fitting fees cover prescription trial lenses and 60 days of follow-up care. If you elect to forego the follow-up care and return beyond the initial 60 day period, an additional visit may be charged ($50). Fitting fees do not cover the cost of contact lens materials and cannot be refunded. The contact lens fitting fees are as follows:

Training for 1st time contact lens wearers: $15.00
Single vision sphere (non-astigmatism): $75.00
Single vision astigmatism: $100.00
Multifocal or monovision (presbyopia): $125.00
Specialty Contact Lens Fittings: $150.00 & up
NOTE: Contact lens services are separate procedures that may not be covered by your insurance. However, some vision plans provide an annual allowance that may be used toward the cost of contact lenses or contact lens service fees. In other cases, insurance may not cover contact lenses at all.

I have read and understand 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: Date:



ABOUT YOUR APPOINTMENT

  • 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 $25 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.