Patient information

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

Billing information

Primary Vision Insurance

Primary Medical Insurance

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

Medical History:

Do you have any of these medical conditions?

Family Eye History

Does anyone in your family have any of these eye conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?

Review Of Systems

Social History

Please read carefully and sign your acceptance by entering your First and Last Name in the boxes below.


I hereby authorize and request that Lookout Eyecare provide such medical care and administer such diagnostic and/or therapeutic procedures and treatments as in the judgment of the optometrist in attendance are deemed necessary and advisable.


Dilation of the eyes involves the use of eye drop medications to widen your pupil. This allows your doctor to get a better view of the health of the eye, think of this as your ocular health physical. Dilation can cause blurry vision especially up close like on a cell phone or computer. The effects of dilation last from 2-4 hours. Most individuals feel comfortable driving home after, but it is advised to set up a driver for your appointment in the case you would like assistance after your exam. The doctors of Lookout Eyecare require dilation for all patients under the age of 13 years old for a glasses or contact lens exam. It is strongly advised for all patients.


I give permission for my doctor to dilate my eyes to better assess my ocular health. I understand this is also included in my exam and not an additional cost to me.

I give permission to dilate AND include Maestro Retinal Imaging ($40) - This is considered standard of care by Lookout Eyecare doctors.

I am declining dilation at this time.

I am declining dilation and would like to perform Maestro Retinal Imaging ($40)

** I understand the doctor will carefully review any findings or abnormalities during my exam. Dilation may still be necessary per the discretion of the doctor.

If you are declining dilation, please read the statement below:

I understand that the exam performed today will include a refraction status evaluation and an undilated eye exam only. This means that the medical conditions like retinal tears, detachments, masses and other conditions may be missed. My doctor recommends a complete medical eye exam with dilation, but I understand the risks and I am declining.

Please read carefully and sign your acceptance by entering your First and Last Name in the boxes below.


I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which I can access in the link below, that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician certifications. I consent for Lookout Eyecare to communicate with me via unsecured encrypted email. If not, I agree to use the secure HIPAA compliant patient portal upon which a unique username and password will be provided to me.

View Notice of Privacy Practices Form


Routine eye wellness exams will be billed to your vision insurance plan and patient responsibility for routine exam or materials copays and coinsurance is due at the time of visit. However, if you have medical conditions, have medical testing, or the doctor uncovers a medical diagnosis as the cause of your presenting symptoms, the exam and/or any associated medical procedures must be billed to your medical insurance carrier. I acknowledge for any visit that I will assume full financial responsibility for services rendered to me if my insurance carrier denies or does not cover my claim for these services.

I understand that I am responsible to pay all co-payments at the time of service. Co-payments cannot be waived at any time by the provider of service or Lookout Eyecare. If my insurance determines that I have not met my deductible, I understand that I will be fully responsible for payment in a timely manner, no more than 30 days after I have been notified by insurance and/or provider. Yearly deductibles cannot be waived at any time by Lookout Eyecare.

I hereby understand and fully agree with office policies ,charges and protocols.

* If patient is a minor: I attest that I am the legal guardian with legal authority to make medical decisions for this minor: