Online Patient Form
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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Preferred Contact Method:
Employer / School Name
Is The Billing Address Different?
Reason for Visit:
History of Present Illness:
Do you currently have any of these symptoms?:
Flashes Of Light
Have you had any eye surgeries? Please describe:
Last Eye Exam:
Last Appointment Type
Primary Vision Correction:
Prescription Reading Glasses
Non-Prescription Reading Glasses
Intrested in Eyelid cleaning?
Intrested in Ortho-K?
Intrested in Contact Lenses?
Intrested in Glasses?
Intrested in Medical Procedures(Select below)?
Dry Eye Treatments
Diabetic Eye Exam
Macular Degeneration Evaluation
No Meds Used
No Known Drug Allergies
Primary Care Physician:
greater than 3 years
Acknowledgment of Notice of Privacy Practices
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.
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
Relationship to Patient:
I understand that
(VSP, EyeMed, etc) are
medical insurances and therefore only cover routine vision services
I understand vision plans do
cover or contribute to chronic management or treatment of ocular disease, medical procedures, or specialized testing
I understand that
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
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
for eyewear purchased outside our office
Unpaid accounts exceeding
are subject to collection fees
There will be a service charge of
on all returned checks
Missed appointments without a courtesy 24-hour notice will incur a charge of
Maestro Retinal Imaging
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
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
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