Jade Optical Online Patient Form

Click here to return to the Jade Optical Website


Patient Information
City: State/ZipCode
Cell Phone: Alerts:
Email Preferred Contact Method:
Other Phone: Last 4 Of SSN
Birthday Occupation
Marital Status Employer / School Name

Vision Insurance

Primary Vision Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:

If you are NOT the primary on your insurance, please fill out the information below:

Primary on Account
Name:Last, First, MI
Relationship to Insured:
City: State: Zip:
Phone Number:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Reason for your visit: -

Ocular History

Do you have any of the following conditions? -

Condition None Grandparents Siblings Parents Self
Macular Degeneration
Lazy / Crossed Eye
Diabetic Retinopathy
Retinal Detachment
Ocular Surgery

Medical History

Medications: - No medications used

Allergies: - No known allergies

Do you have any of the following conditions? -

Condition None Grandparents Siblings Parents Self
High Blood Pressure
High Cholesterol
Thyroid Problems
Heart Conditions

Outpatient Division Screening for COVID-19

1. As of today, are you COVID-19 positive or actively infected with COVID-19 virus? Yes No

Office Policies

Acknowledgement and Assumption of Risk

Jade Opticalhas taken all precautions recommended by the Centers for Disease Control and Prevention for business to provide services to customers during the COVID-19.Additionally, Jade Opticalhas been screening our employees before every work shift to ensure that no employee is suffering any of the known symptoms of COVID-19, including running a fever, having a dry cough, or experiencing shortness of breath. However, it is also knownthat those without symptoms may still be capable of infecting others as an asymptomatic individual with COVID-19and despite precautions taken the virus may still be present and capable of infecting individuals.

Knowing this information, I voluntarily elect to continue with my scheduled appointment with JadeOpticaland I hereby agree to accept and assume any and all risks of personal injuryor death.

Waiver of Liability and Indemnification
In consideration for being treated by Jade Optical,on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I:

a. waive, release, and discharge Jade Optical, its agencies, officers, and employees from any and all negligence and liability for my death, disability, personal injury, or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced appointment; and

b. defend, indemnify, and hold harmless Jade Optical, its agencies, officers and employees, from any and all claims of any nature, including all costs, expenses, and attorney's fees, which may in any manner result from or arise out of this agreement, except for claims resulting from or arising out of Jade Opticalwillful or intentionalnegligence.

This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.

I, the undersigned, affirm that I am at least 18 years of age and am freely signing this agreementor that I am signing on behalf of a minor child that I have the legal authority to sign such agreements on behalf of. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my appointment. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.

Read Before SigningRead Before Signing

Signature: Date:

Signature (Parent / Guardian): Date:

Retinal Photo Test

Digital Retinal Photo Screening
for Detection of Medical Eye Disorders

The Digital Retinal Photo Screener takes a photo of the inside portion of the eye. No eye drops, no discomfort!

The Digital Retinal photo can detect ocular diseases such as:
  • Glaucoma
  • Macular Degeneration
  • Retinal Detachments
  • Ocular Cancer
  • Diseases of the arteries and veins of the retina
  • Retinal tears & Macular Holes

  • The Digital Retinal photo can also medical conditions associated with your general health such as:
  • Diabetes
  • High Blood Pressure
  • High Cholesterol
  • Thyroid related Problems

  • The doctor strongly recommends this screening test, especially for first time patients. This allows for a more thorough examination of the eye. The digital photo also serves as baseline documentation that allows the doctor to monitor your health every year with more accuracy and detail. This photo stays on your file for life and can easily be shared with other doctors such as Primary Care Doctors and Ophthalmologists when needed for better patient care. Our staff will happily provide you with a digital copy for your records upon request.

    There is a fee of $39.00 for the digital photo screening exam. You'll be given a receipts, as your insurance plan may reimburse you for this medical procedure. Our staff will let you know if your insurance covers this service. This screening test does NOT substitute a dilated eye exam but helps view the patient's ocular health with more detail and thoroughness when looking through a non-dilated regular pupil.

    I have read and understand the information regarding the Digital Retinal Photo Screener.

    Check the appropriate line below, sign and date:

    YES, I do want the Digital Photo Exam NO, I do not want the Digital Photo Exam

    Policies, Consent and Submit Data




    We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


    We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

    Treatment: We may use or disclose your health information to an optician, ophthalmologist or other healthcare provider providing treatment to you for: a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d) recall information.

    Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities; and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement.

    Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include things such as quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

    Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

    Marketing Health Products or Services: We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health information without your prior authorization.

    To You, Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.

    Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

    Required by Law: We may use or disclose your health information when we are required to do so by law, including judicial and administrative proceedings.

    Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

    National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

    Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and services that may be of interest to you.


    Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

    Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years, but not for disclosure made prior to April14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

    Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

    Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

    Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

    Electronic Notice: If you receive this Notice on our a Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.


    If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

    Please check, sign, and date that you have read and agree to our policies and click the SUBMIT button to complete your online forms. Thank you!

    Patient Signature: