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


Title First Last MI Suffix Nickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address Different?
Title First Last MI Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Plan

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Plan 2

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

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:
Primary Reasons: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:
Want new glasses? Want backup sunglasses?:

Medical History

Please describe any injuries or surgeries you have had:

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


Do you have any of these medical conditions?:

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

Family Medical History



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

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

Family Eye History

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

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

Review of Systems

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

Social History

Hobbies:

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

Race: Ethnicity: Preferred Language:
STD

Submit Form / Patient Signatures



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

I, acknowledge that I have received a copy of the Notice of Privacy Practices from Perfect Vision Eyecare & Eyewear.

I have listed individuals that are authorized to receive my protected health information. I am aware that I can revoke the authorization for any individual at any time, but must do so in writing.

Patient Signature: Date:

Signature Of Patient Representative & Relationship: Date:
(Required if patient is a minor or an adult unable to sign form)

The following individuals have my authorization to access my Protected Health Information

Name: Relationship: Date Of Birth:

Name: Relationship: Date Of Birth:

Name: Relationship: Date Of Birth:

Name: Relationship: Date Of Birth:

Financial Responsibility Medical/Vision Insurance

Most people have vision insurance and medical insurance. They are very different in terms of the services they cover, and it is important for our patients to understand those differences.

Vision coverage (VSP, EyeMed, Spectera, etc.) is mainly designed to determine a prescription for glasses or contacts and is not equipped to deal with complex medical conditions or diagnoses. It does allow for screening of conditions, but once they are determined, medical insurance is filed for those services.

When a medical condition is present (diabetes, cataracts, dry eye, floaters, etc.) it is necessary to file the visit with your major medical carrier. Co-pays and deductibles will apply based on your specific plan. There may also be non-covered services that you or the guarantor would be responsible for. In some instances, the medical cases will need to be treated before we able to perform routine vision services.

If you have a pre-existing medical eye problem, we will be filing your medical insurance. We make every effort to be on every major carrier for your convenience, and we will file those claims for you. In the event that we do not take your insurance, we will provide you with an itemized receipt so that you may file with your carrier for reimbursement.

I, have read and understand the information above and authorize Perfect Vision Eyecare & Eyewear to file insurance on my behalf. I hereby assign and request that payment of all medical benefits be made to Perfect Vision Eyecare & Eyewear. I authorize the release of all medical and other information necessary to process claims. I understand that I am financially responsible for all non-covered charges incurred while under the care of Perfect Vision and their doctors. I also acknowledge that any unpaid balances may be subject to collections and is the responsibility of the guarantor.

Patient / Guardian Signature: Date:

Contact Lens Policy and Fee Schedule



At Perfect Vision Eyecare & Eyewear, it is our intention to provide our patients with the best possible contact lens services and materials available. Therefore, we are continually updating our lens inventory and services with the latest technology and information. Before a patient can be evaluated for contact lenses, a complete comprehensive eye exam with refraction must be completed. The contact lens evaluation must be done within 90 days of the comprehensive exam.

CONTACT LENS FITTING AND CORNEAL EVALUATION

By law, a contact lens prescription is only valid for one year from the date of service and a patient must be evaluated annually to receive a new prescription. The goal of a contact lens evaluation/fitting is to find the most appropriate contact lens to optimize each patient’s comfort and eye health. In most cases, patients will only need one appointment to determine the best contact lens option. However, in some cases, a patient may need several sessions to determine the best fit. These are known as follow-up appointments. The contact lens evaluation/fitting session will include a pair of trial lenses, insertion and removal training (for new wearers), and two follow-up visits at no charge within 45 days. Trial lenses will only be given to patients with an appointment. There will be a $30 fee for ay follow-up visits after 45 days.

FOLLOW UP APPOINTMENTS

Follow-up appointments allow the doctor to evaluate the following:
  1. The contact lenses are fitting on the eyes properly
  2. The prescription is providing the best possible vision
  3. The eyes are remaining healthy
  4. There are no problems with insertion and removal of lenses
  5. The patient is comfortable with and understands the care and wear schedule of the contacts

CONTACT LENS FEE

Contact lens exams are considered elective. Therefore, they are not covered by most insurance plans. However, many insurance plans will offer a discount for this service. Fees for the contact lens evaluation or fitting are due at the time of service and are non-refundable. Once the prescription is finalized, patients can order over the phone or on our website as long as the prescription is valid.

REFUND

There will be no refunds on custom lenses, opened boxes of contacts, or colored lenses because of dissatisfaction with color. We will exchange unopened and damaged boxes and issue a credit on your account for those boxes as long as they were purchased through our office within the last year.

FEE SCHEDULE

LEVEL 1 SPHERICAL SINGLE VISION $75
LEVEL 2 TORIC SINGLE VISION / EXTENDED WEAR $85
LEVEL 3 NEW PATIENT / NEW FIT SPHERICAL OR TORIC SINGLE VISION $110
LEVEL 4 MULTIFOCAL SPHERE / MONOVISION / TORIC SINGLE VISION XR $130
LEVEL 5 MULTIFOCAL TORIC / RGP / MEDICALLY NECESSARY $150
LEVEL 6 SCLERAL SINGLE VISION / ORTHO-K / MYOPIA MANAGEMENT $850
LEVEL 7 SCLERAL MULTIFOCAL $950


I have read and understand the Contact Lens Policy and Fee Schedule. I have given the opportunity to ask any question I have regarding this policy and will be given a copy upon request.

Patient Signature: Date: