Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

Reason for Visit

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History of Present Illness

Do you currently have any of these symptoms?

Have you had any eye surgeries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Medical Procedures

Medications

Medications No Meds used

Drug allergies No Known Drug Allergies

Primary Care Physician

Last Visit

Reason

Acknowledgment of Notice of Privacy Practices

Click here to read the full Privacy Policy

The law requires that DeNovo Eye make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

I was given the opportunity to read, have read or had explained to me DeNovo Eye's Notice of Privacy Practice prior to any services offered.

The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible

I authorize DeNovo Eye to release my personal health information to the following individuals

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Patient Signature

Date

If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor

Representative Signature

Relationship to Patient

Financial Disclosure

I understand that vision plans (VSP, EyeMed, etc) are NOT medical insurances and therefore only cover routine vision services

I understand vision plans do NOT cover or contribute to chronic management or treatment of ocular disease, medical procedures, or specialized testing

I understand that medical insurance will be necessary to cover or contribute to medical diagnoses, management or treatment of ocular disease, or other medical procedures

I understand that in order to maximize my usage of benefits, DeNovo Eye requires all patients to present both medical insurance and vision plan information at the time of scheduling appointment

DeNovo Eye requests that all professional services, material charges, and fees be paid at the time services are rendered by the patient unless other written arrangements are made in advance

The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance coverage

Custom eyewear measurements performed by our trained opticians, including pupillary distance (PD), are included at no cost when purchasing eyewear through our office. We do provide this service for $45.00 for eyewear purchased outside our office

Unpaid accounts exceeding 90 days are subject to collection fees

There will be a service charge of $30.00 on all returned checks

Missed appointments without a courtesy 24-hour notice will incur a charge of $45.00

Maestro Retinal Imaging = $45.00

This is an out-of-pocket expense not covered by Vision Plans

This test is part of our comprehensive eye exam to establish an ocular health baseline for ALL of our patients, and is part of our standard of care

I understand this test is NOT OPTIONAL as per our office policy and will be performed on every comprehensive exam

I understand that this is Non-Covered Service by any Vision Plan (VSP/Eyemed) and therefore is NOT included with "routine exam" copays

Routine dilation will be performed in addition to this test as per the discretion of the doctor for each individual case based on medical necessity

Your doctor will carefully review any findings or abnormalities during your exam

Patient Signature

*This field is required

Date

Privacy Policy [https://www.crystalpm.com/6844/PrivacyPolicy.pdf]
Financial Disclosure [https://www.crystalpm.com/6844/FinancialDisclosure.pdf]

Patient Signature Sign your name:


Please ADD the above numbers together.