New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:


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Primary

Primary Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:


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Secondary

Secondary Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:


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Supplemental

Supplemental Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

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Medical History

**Please complete all entries below, then push "submit" button on next tab to submit information to our office **



Be sure to SUBMIT FORMS from the last tab



List any Ocular History  (Lasik, eye surgery, eye trauma, lazy eye, cataract surgery)


List any Allergies (Seasonal, allergies to drugs, foods, medications)


Surgeries/Injuries (Heart surgery, trauma to head, major accidents, etc)


Medications and Eye Drops (list any medications currently taking, including eye drops)




**Social History **

Alcohol use (Y/N)    

Pregnant/Nursing? (Y/N)       

Smoking          

Rec Drugs (Y/N)     

Drives (Y/N)            

Hobbies                   
 
 

**Personal History** (select all that apply to you)


Gastrointestinal Neurological Respiratory Genitourinary
Colitis Headaches Asthma Bladder Problems
Crohns Dz Seizures Bronchitis Kidney Problems
Ulcers Migraines Emphysema STD's
Constipation Multiple Sclerosis
Diarrhea
 
Constitutional Endocrine Cardiovascular Allergic/Immune
Fever Type I Diabetes Heart Dz Drug Allergies
Weight loss/Gain Type II Diabetes High Blood Pressure Seasonal Allergies
Fatigue Thyroid Dysfunction High Cholesterol Arthritis
Trauma
 
Skin Ears/Nose/Throat Musculoskeletal Lymph/Blood
Eczema Allergies Osteoarthritis Anemia
Rosacea Dry Mouth Fribromyalgia Bleeding Problems
Psoriasis Sinus Congestion Ankylosing Spond. Leukemia

Other

**Family Medical History ** (Check if any family members have or have had condition. Specify which family member in box open box next to condition)

Blindness     Cancer
Cataracts     Diabetes
Macular Degen     Heart Dz
Glaucoma     High BP
Retinal Detach     Kidney Dz
Crossed Eyes     Arthritis
Thyroid Dz     Lupus


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Contact Lens Fit / Eval



Contact Lens Fitting and Evaluation Agreement



If you are a current contact lens wearer, or are interested in wearing contact lenses, you will need a contact lens evaluation.

The goal of a contact lens evaluation (fit) is to find the most appropriate contact lens for each patient's optimal vision and comfort. Before a person can be fit with contact lenses, a complete medical and refractive eye examination is necessary. This exam is critical to assure the good health of your eyes and to rule out the possibility of any unsuspected, underlying condition that may prevent contact lens use

The contact lens evaluation (fit) fee is not included in the fee for your eye exam and is usually not covered by your insurance. The fee for your contact lens evaluation includes the initial visit and visits directly related to contact lens wear within a 90 DAY PERIOD. The fee also includes contact lens training class for new wearers. The fee is due in full at time of the fitting evaluation and is not a refundable service rendered.

The fees for the contact lens evaluation (exam) are as follows:

FEE
Conventional , Spherical Contact Lens$60
Toric / Astigmatism Contact Lenses$86
Monovision Contact Lenses$116
Multifocal / Bifocal Contact Lenses$116
Gas Permeable (RGP) Contact LensesStarts at $116


Dr. Birkmann will examine the health of your eyes annually to ensure that you are a proper candidate for contact lenses.

You are responsible for scheduling and attending your follow up visit to finalize your prescription. Without a finalized prescription, you will not be able to order contacts

By signing below, you are acknowledging that you have read and understood our contact lens policy and agree that you will pay in full at time of service.

I would like a contact lens evaluation today.

I do not want a contact lens evaluation today and I am aware that, without it, I cannot order contacts.

Patient Name (Or Responsible Party):
Date:

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HIPAA Privacy Policy

HIPAA Privacy Policy



Consent to Treat: I have requested medical services from Georgetown Vision Center on behalf of myself and/or my dependents. I agree to and understand that my Doctor may request that my eyes be dilated as part of a comprehensive eye exam. I understand that if my pupils are dilated, I may not be able to safely operate a motor vehicle and that the staff and doctors of Georgetown Vision center request that I arrange alternate transportation.

Payment and Financial Information: Payment is due at the time services are rendered. Accepted methods of payment are cash, check, or credit card. Accounts that become delinquent may be referred to a collection agency, and you are responsible for collection costs in addition to your outstanding balance. There is also a $30.00 fee for checks returned by the bank.

Insurance Information: Please provide insurance information prior to your appointment, and present ALL insurance cards at the Front Desk during check in. Georgetown Vision Center will bill those plans for which we have an agreement and will require you to pay the authorized co-payment/co-insurance at the time of service. If it is determined that you do not have benefits to cover today's visit, you have been seen out of network, or your insurance determines that services are not covered, please understand that you are responsible for payment of today's services.

(initial) I certify that the insurance information that I have given is correct, and I authorize Georgetown Vision Center to act as my agent in helping to obtain payment for services and materials furnished including the release of any information necessary to insurance carriers regarding my diagnosis and treatments to process the claims. This order will remain in effect until revoked by me in writing.

Acknowledgement of Privacy Practices and Policies: I have been made aware of and/or reviewed this office's Notice of Privacy Practices, which explains how my medical information may be used or disclosed. I understand that I am entitled to receive a copy of this document upon request

Cancellation Policy: We require 24 hours of notice to cancel or reschedule your appointment; otherwise we reserve the right to charge a $50.00 fee for time reserved. Excessive cancellations may also put your account on a nonrefundable prepay basis only.

Authorization for Release of Identifying Health Information: If you are 18 years or older and you want another person or family member to have access to your medical records, account information, or prescription, please indicate by providing details below.

I , authorize Georgetown Vision Center to release health information about me, including personal health, account and insurance information in my records to the following:

Name / Relationship: Phone:

Name / Relationship: Phone:

Signature Of Responsible Party: Date:

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IWellness

IWellness Exam Form



In an effort to provide a more thorough eye examination Georgetown Vision Center has incorporated the i-Wellness Exam, which includes the SD-OCT scan and Retinal Imaging as part of our comprehensive eye exam.

Like an MRI of the eye, but taking only seconds to perform, the SD-OCT provides high definition cross sections of your retina and optic nerve which can reveal signs of disease in exquisite detail that are invisible to traditional examination methods. Retinal Imaging captures comprehensive digital images of the surface of the retina.

We strongly recommend this procedure as part of your exam if:

  1. You are a new patient to this office
  2. You cannot be dilated (does not replace dilation)
  3. You are 65 or older
  4. You have or have family history of glaucoma, macular degeneration, and/or blindness.
  5. You have or have a family history of diabetes
  6. You have headaches or visual disturbances suggestive of a neurological problem
  7. You have any other retinal disorder such as a detachment, floaters, flashing lights, bleeding
  8. Your vision is not correctable to 20/20 in one or both eyes


The charge for the i-Wellness Scans is $29 in addition to the normal exam fees. Although not typically covered by insurance, it is an eligible expense with Flexible Spending Accounts.

Yes, I choose to have the i-wellness scans performed today.

No, I wish to decline the scans today.


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Submit



Signature Of Responsible Party: Date:

*** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I accept has the same validity and meaning as my handwritten signature.

Thank you for taking the time to fill out our online History Questionnaire form.

You may click on each tab above to review the information you have provided.

Please be sure you have filled out BOTH the Demographics tab AND the Medical History tab and any applicable insurance tabs before clicking submit.

Please make sure to click on the "Submit Data" button below to securely submit your information.

Is it OK to call you for your yearly exam reminder?

To avoid a $50 fee, you must provide at least 24 hours notice of cancellation or rescheduling.