Patient Forms

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Medical History

Reason for Visit

*This field is required

History of Present Illness

Do you currently have any of these symptoms?

Have you had any eye surgeries? Please describe

Last Eye Exam

By Doctor

Please include any additional pertinent ocular history

Medications

Medications No Meds used

Drug allergies No Known Drug Allergies

Primary Care Physician

Last Visit

Primary Care Physician Contact Tel and Fax

Preferred Pharmacy

Pharmacy Tel and Fax

Family Ocular History

Please include any pertinent family ocular history

Medical History

Please include any pertinent systemic medical history

Family Medical History

Please include any pertinent family medical history

Acknowledgment of Notice of Privacy Practices

Click here to read the full Privacy Policy

The law requires that Innovista 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 Innovista 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 Innovista Eye to release my personal health information to the following individuals:

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

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 wellness or 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 performed

I understand that in order to maximize my usage of benefits, Innovista Eye requires all patients to present both medical insurance and vision plan information at the time of scheduling

All professional services, material charges, and fees are due at the time services are rendered, unless other written arrangements are made in advance

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

Due to varying quality in materials, proprietary lens technology, and services obtained at other clinics and retail settings, all verification and rechecks of glasses prescriptions and/or eyewear measurements that have been purchased and/or manufactured outside of Innovista Eye will incur a $45.00 charge for our professional time

Unpaid accounts exceeding 90 days are subject to collection fees

Initials

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

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

Refraction testing is NOT a covered service by Medicare and other third-party medical carriers - this is a $65.00 out-of-pocket service that is due at the time of comprehensive evaluations and/or when glasses prescriptions are given

Contact lens exams and services start at $120.00 in addition to the exam fee depending on the type, complexity, plan coverage, etc. This includes all necessary testing and imaging, as well as 60 days of no charge visits to finalize a prescription. Please notify us if you are interested in specific contact lens services for a more accurate estimate. Exchanges and/or returns of any contact lens materials will incur a restocking fee and must be of equal or lesser value.

Digital Ocular Imaging = $45.00

Similar to dental imaging, this is a comprehensive, digital, multi-image ocular scan that assess the optic nerve, retina, and other structures of the eye down to the micron scale to detect early disease

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 cannot be unbundled as per our office policy and will be performed on all comprehensive exams

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

Initials

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

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

*This field is required

Date

Privacy Policy [https://www.crystalpm.com/8899/PrivacyPolicy.pdf]
Financial Disclosure [https://www.crystalpm.com/8899/FinancialDisclosure2025.pdf]

Patient Signature Sign your name:


Please ADD the above numbers together.

Patient information