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


TitleFirstLastMISuffixNickname
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 The Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary Insurance

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

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:

Tertiary Insurance

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:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

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

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


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



HIPPA: Acknowledgment of Receipt of Privacy Notice

By signing this acknowledgment of Receipt of Notice of Privacy Practices (the "Notice"); I acknowledge and agree that I have received a copy and/or read a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below.

I understand that the office may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the office to perform its administrative duties, provide me with eye care services and products, process my vision/medical benefit claims and communicate with me regarding vision/medical claims and communicate with me regarding vision/medical care services provided by the office (for example, mailings of exam reminders or information for services/products provided by the office).

I can be assured that this office does not sell my personal health information of any kind to a third party for such party's own use. I authorize the office to submit my vision/medical benefit claims to my plan sponsor or health plan to receive reimbursement directly for the vision/medical services/products that I have received from the office.

Patient Lifetime Signature or Patient's Legal Representative Date:

INSURANCE SIGNATURE ON FILE

I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly to the doctor on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage, my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as my agent, as above. I understand I am responsible for the balance of fees not paid by my insurance.

Patient Lifetime Signature or Patient's Legal Representative Date:

REFRACTION POLICY: * FOR INSURED PATIENTS ONLY *

The Centers for Medicare and some insurance companies consider a refraction to be a NON-COVERED service. Please be aware it is the responsibility of the patient to pay for the refraction unless otherwise stipulated by your insurance carrier. Our office currently charges $95.00 for this procedure, but provides a prompt pay price of $45.00 to the patient when paid at the time of service. The refraction fee is paid in addition to the eye exam co-pay. I have read the above information and understand I may be charged a prompt pay price of $45.00 at the time of service unless otherwise stipulated by my insurance company.

Patient Lifetime Signature or Patient's Legal Representative Date:

Electronic Communication

Please be advised that any communications we received from you, the patient, through electronic means, such as text or email, will be unsecured. Our office will not send any health or medical records to you through these channels, unless requested by you. Our office will always strive to protect your records through proper means.

By signing this, you fully have understood and accepted all the risks involved in an open channel communication.

Patient Lifetime Signature or Patient's Legal Representative Date:

Dilated Fundus Exam:

Dilation provides a more comprehensive internal ocular health analysis of the eye. The side effects include temporary blurry vision at near, some blur at distance and light sensitivity. This procedure is included with your comprehensive exam. There is a $25 FEE charge charge if patient have this procedure after 30 from the time of exam.

Yes. I want the Dilated Fundus Exam I will ask the Doctor

Optomap Retinal Exam:

An effective computerized imaging that scans 80% of your retina to help your Doctor evaluate, monitor, and treat various eye conditions. Our staff will scan your eye at the time of your exam, and your doctor will ask to review the images. If you agree to the viewing, there is a $42 FEE for the Doctor to review the images with you.

Yes. I want the Dr. to review the Optomap I will ask the Doctor

Visual Field Analyzer:

A visual field screening can assist us in early detection of glaucoma, retinal problems, and some neurological diseases and may diagnose causes of headaches. There is a $25.00 fee for the visual field screening.

Yes. I want the Visual Field Analyzer I will ask the Doctor

I understand that without these tests, certain eye diseases and conditions may not be discovered. I agree to assume all risk associated with refusing these tests, indemnify, hold harmless, and release Ella Eyes, its employees and optometrists, from any and all claims or liability whatsoever related to failure to diagnose and/or treat any eye conditions due to lack of diagnostic information which could have been obtained by these tests.


All PROFESSIONAL SERVICES ARE DUE AT TIME OF SERVICE AND ARE NON-REFUNDABLE
**There is no fee for follow up visits on glasses or contact lens fitting within 30 days from initial exam. Any follow ups on glasses or contact lens past 30 days will be charged an office visit fee.

Patient Signature or Patient's Legal Representative Date

Refund/Remake Policies

  1. We will make your lenses according to your Doctor's written prescription. Our goal is to provide the highest quality products and the best possible service.
  2. We CANNOT CANCEL your order or REFUND your lenses after your lenses has been ORDERED/ PROCESSED including partial deposits.
  3. Patient understands that frame choice is FINAL once the lenses have been processed
  4. Patients experiencing adaptation issues to any prescription MUST return within 30 days from the date of purchase for a 1 time remake.
  5. No Refunds will be given to patients that do not adapt to their prescriptions. We offer to REMAKE the lenses within the 30 days from the date of your order.
  6. Ella Eyes standard policies include 30 days of customer satisfaction in which we will gladly adjust, repair, or equally exchange your new glasses if there are any defects.
  7. We offer a one time, within the year of purchase, a SCRATCHED lenses warranty of the same RX REMAKE at no charge.
  8. We offer to replace your BROKEN OR DAMAGED glasses 1 time with the same or equivalent product at a 50% off retail pricing up to 1 year from the date of your purchase. We do not cover lost or stolen glasses.
**Patient acknowledges receipt of Ella Eyes @ Woodway Collection "Remake & Refund Policies" and fully understands the policies.**

Patient Signature or Patient's Legal Representative Date

Contact Lens Service Agreement

Contact lens wear is a type of correction that requires commitment and good hygiene. Not everyone can wear contact lenses successfully. There are many factors that can influence the success of your fit such as allergies, oily tears, dry eyes, medications, improper care or failure to return for follow-up visits. It is not always possible to determine in advance whether you will be those who will successfully enjoy contact lens wear. Even with the best fit, contact lens vision, in some cases, may not be as clear and comfortable as spectacle wear.

Eye Infections can occur even with proper contact lens usage and care. Contact lenses can also cause red eyes, blurred vision, light sensitivity, itchiness, mucus build-up, and can become uncomfortable. Lenses should not be worn if these conditions occur. If these conditions occur, an OFFICE VISIT should be made immediately.

Follow-up visits are extremely important. It is the patient's responsibility to return to the doctor when the contact lenses are dispensed and for routine follow-up visits per the doctor's instructions. It is also necessary for the patient to return for a routine eye exam every 12 months or sooner as all spectacle/contact lens prescriptions will expire one year from the date of the initial exam unless specified by the doctor.

The contact lens exam includes an eye exam, contact lens fitting, and (3) follow-up visits for one month per doctor's instructions, from the initial date of the exam. If the patient does not return for the scheduled visits within the allowed time, then there will be a fee accrued for visits after the month is up.

All fees charged for the EXAMINATION, FITTING, and SERVICE AGREEMENT (conventional, disposable, and planned replacement) are NON-REFUNDABLE.

I HAVE READ, UNDERSTOOD, AGREED to the ABOVE CONTACT LENS AGREEMENT

Patient Signature or Patient's Legal Representative Date

Contact Lens Digital Consent

I authorized my eye doctor to provide me with a digital copy of my contact lens prescription by,

Patient Portal (Most Secure) Email Text

at the end of my contact lens fitting.

Patient Signature or Patient's Legal Representative Date