Online Patient Form

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Patient Information

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

Billing Information

Is The Billing Address Different?

Medical History

Reason for Visit:
Primary Reason: 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:
Intrested in Eyelid cleaning?
Intrested in Ortho-K?
Intrested in Contact Lenses?
Intrested in Glasses?
Intrested in Medical Procedures(Select below)?
Medical Procedures:


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:


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
The undersigned will ultimately be responsible for any remaining balance after insurance coverage has been applied.

I hereby understand and fully agree with the above office policies, charges, and protocols
Patient Signature: Date:

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