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

City: State: Zip Code:
Other Phone:
Cell Phone: Preferred Contact Method:
Sex Misc/Guardian

Billing Information

Is The Billing Address the Different?
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

Drug Allergies:

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

Do you have any of these medical conditions?:

High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:

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


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:

    Patient Dilation Consent Form

    Dilating the pupil with eye drops allows your doctor to obtain the most optimal view inside your eyes in order to prevent and treat eye health. Health problems such as glaucoma, cataracts, retinal degeneration, diabetes, and high blood pressure can be detected even before the onset of any symptoms or loss of vision. It is possible that some of these eye conditions can go undetected without dilating your pupils.

    It is highly recommended to have your eyes dilated if:

  • This is your first eye examination.
  • Your eyes were never dilated.
  • You are new to our office.
  • Your last eye examination was more than 5 years ago.
  • You are over the age of 40.
  • Have been previously diagnosed with a condition that needs yearly monitoring (as in diabetes, high blood pressure, etc.)
  • You have had a recent onset of reduced vision, floaters, or flashes of light.
  • You have glasses or contact lens prescription over -3.00.

  • If you do not fit in the above categories, it is still recommended to have your eyes dilated at least every 2 years.

    Please be advised that dilation will last anywhere from 2-4 hours and you may experience sensitivity to light and blurred vision when reading. Most people will be able to drive once their eyes are dilated, however, if you feel uncomfortable driving, or have never driven with your eyes dilated, it may be best to have a driver. Please note there is no additional charge for having your eyes dilated, as it is included in your comprehensive eye exam.

    Please check one of the following:

    YES, I would like my eyes dilated today if the doctor believes it is necessary.
    I would like to speak with the doctor about dilation.
    NO, I do NOT want my eyes dilated (see below).

    In refusing to have my eyes dilated, I understand that I am assuming all risks associated with failure to diagnose eye conditions due to lack of information, which may have been provided by this test.

    Patient Signature: Date: