For our office staff to recieve your information you must finish all 5 tabs above and click the big green "Submit Data" button at the bottom of the last tab that says "Patient Signatures and Submit Data"

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

For our office staff to recieve your information you must finish all 5 tabs above and click the big green "Submit Data" button at the bottom of the last tab that says "Patient Signatures and Submit Data"

Primary Vision Insurance



Primary Medical Insurance

For our office staff to recieve your information you must finish all 5 tabs above and click the big green "Submit Data" button at the bottom of the last tab that says "Patient Signatures and Submit Data"

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

For our office staff to recieve your information you must finish all 5 tabs above and click the big green "Submit Data" button at the bottom of the last tab that says "Patient Signatures and Submit Data"


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

CONSENT FOR MEDICAL TREATMENT

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 & RETINAL IMAGING CONSENT


Lookout Eyecare is committed to offering ALL our patients the most thorough eye health examination available. This is performed through
advanced retinal imaging and dilation. This allows the doctor to evaluate the internal parts of the human eye and is part of our standard of care.



Advanced Retinal imaging is extremely important because it allows the doctor to uncover and document problems such as glaucoma, macular degeneration, hemorrhages, retinal detachments, tumors, and other eye diseases much earlier than normally possible. In addition, retinal imaging can reveal problems associated with systemic diseases such as diabetes, vascular disease, hypertension, and many others. This also provide a permanent record for comparing future changes and could alleviate the need for dilation.


Dilation is always included in your complete eye exam. This involves the use of eye drop medications to widen your pupil. This allows the doctor to get a better view of the health of the eye - like an ocular health physical. Dilation can cause blurry near vision and light sensitivity which may last approximately 4-6 hours. Most patients feel comfortable driving home after, but it is advised to set up a driver for your appointment in the case you need assistance.


Please choose one of the following:


Retinal imaging and dilation (additional $59)

dilation only and no retinal imaging (include in exam)

No to retinal imaging and dilation**

No sure, I would like to speak with technician and/or doctor first.


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

HIPAA


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



INSURANCE COPAY & DEDUCTIBLES


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: