Online Patient Form

Click here to return to 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


FirstLastMISuffix
Address:
City: State: Zip Code:
Other Phone:
Cell Phone: Preferred Contact Method:
Email
Birthday
Sex Misc/Guardian

Billing Information

Is The Billing Address the Different?
FirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:

Medical History

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

Eye History

Reason for Visit:

Do you currently have any of these symptoms?:
Have you had any eye surgeries? Please describe:
Last Eye Exam:

Primary Vision Correction:

Medical History

Medications:
Drug Allergies:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:


Do you have any of these medical conditions?:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Eye History

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

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

Social History

Hobbies:

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

Submit Form / Signatures


About Your Insurance

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

Medical insurance (such as BCBS and Medicare) must be used if you have any eye health problem or systemic health problems that has ocular complications. Your doctor will determine if these conditions apply to you.

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.

Guarantor (Responsible Party)

Name:          Date Of Birth:

Primary Vision Insurance                                        Primary Medical Insurance
Company Name: Company Name:
Policy ID No.        Policy ID No.       

MEDICAL INSURANCE POLICY: As part of our services at this practice we are happy to assist you in determining the benefits of your individual policy and in collecting your reimbursement of insurance benefits for medical services. To avoid any misunderstandings please read the following statements carefully.

  • The legal obligations of your insurance provider are between yourself and your provider, not between this practice and your provider.
  • When your insurance provider(s) has settled your plan’s covered items, you will be notified by a monthly statement if there were any unpaid balances. Unpaid balances can include non-covered items or series, co-pays, deductibles, lapses, ineligibility or termination of coverages. Unpaid balances are the sole responsibility of the patient.
  • To keep the cost of records and collections down any patient portion amounts on your order will be due at the time of service.
  • I authorize the use of this form on all insurance submissions as well as authorizing the release of information to all my insurance companies as well as allowing the doctor to act as my agent to help me in obtaining payment from my insurance companies.
  • I authorize payment to be made directly to the provider and permit a copy of this authorization to be used in place of the original.


    • CONSENT FOR TREATMENT: I hereby provide authorization to administer diagnostic and medical procedures as may be necessary for proper health care. I acknowledge that I am able to obtain Clarifeye Total Eye Care’s Notice of Privacy Practices and release the right to file insurance given.

    Patient Signature (or parent/guardian signature if patient is a minor): Date:

    Retinal Imaging Consent Form



    Our office offers Digital Retinal Imaging. This non-invasive imaging test allows the doctor to see a much more detailed view of the retina than with traditional methods. The image becomes a permanent part of your medical file, allowing the doctor to make important comparisons year over year. In many cases, there will not be a need to dilate after this process. If the doctor decides that there is a need for dilation, this will be discussed during your exam.

    These images will help see early signs of many ocular and systemic diseases such as:

  • Glaucoma
  • Age related macular degeneration
  • High blood pressure
  • Diabetes
  • Retinal holes or detachments


    • Either traditional dilation OR Retinal Imaging ($35 fee) is an essential part of your comprehensive eye exam and is prescribed for all patients once per year.

    Please check one of the following:

    YES: I understand the importance of Retinal Imaging and would like to have it performed ($35 fee)
    NOT SURE: I would like to discuss with the doctor first.
    NO: I elect to have my eyes dilated (no additional charge). I understand that it will cause light sensitivity and may blur my vision for about 2-4 hours.
    I decline both dilation and Retinal Imaging and understand that a comprehensive examination has not been performed. I understand that I am assuming all risks associated with failure to diagnose conditions, which may have been provided by these tests.

    Patient Signature: Date: