Online Patient Form

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After completing all the forms, please submit your data using the botton at the bottom of the page. Thank you!

Patient Information

Title: First: Last:
MI: Suffix: Nickname:
Address: Apt/Suite #:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Cell Phone:
Alerts: Contact Method:
SSN: Email Address:
Date Of Birth: Occupation:
Marital Status:
Employer or School Name:
Parents Names?:

Billing Information

Title: First: Last:
MI: Suffix:
Address: Apt/Suite #:
City: State: Zip Code:
Home Phone: Work Phone:

Patient History

What Is The Reason For Your Exam Today?


Please Check The Box To Indicate "Yes" To The Questions

How many hour per day do you use a computer/tablet/phone?

Do you have any unique or special visual demands (work or hobbies)?

Are there activities you enjoy but are restricted to because of your vision?

Would you like to correct your vision without using glasses/contacts/surgery?

Please Put A Check In The Box If You Have (Or Have Had) Any Of The Following:



If Female

Current Medications: (Please List)

Please List Any Allergies:

Are There Any Other Medical Illnesses/Conditions?

Who Is Your Primary Care Physician?

When Was Your Last Physical Exam?:

Do You Use Tobacco?

Do You Use Alcohol?

What Is Your Height?
What Is Your Current Weight In Pounds?

Please Check Any Family Related Conditions And Indicate Which Family Member In The Boxes Below The Condition




For Children 12 And Under Only



Is Your Child Adopted?

If yes, does the child know?

Age when adopted?

Full Term Pregnancy?

Normal Birth?

Were There Any Complications before, during or after delivery?

Was the child exposed in utero to:

Did your child crawl?

When Did Your Child First Walk?

When Did Your Child First Speak Words?

When Did Your Child First Speak Sentences?

When Stressed Or Under Tension, is there any pattern of behavior, thumb-sucking, etc?

Has your child had occupational therapy?

Has your child had physical therapy?

Has your child had speech therapy?

Has your child had academic help outside school (i.e. reading specialist)?


What Age Did Your Child Begin School?

Does Your Child Like School?

Was a grade repeated?

Which one?

Is Your Child's School Performance:

Have there been any school difficulties?

Which subjects are easiest?

Which subjects are hardest?

Does testing cause anxiety?

Has your child been retained?

Does the school consider your child to have a learning problem?

Does the school consider your child to have a behavior problem?

Does your child like to read?

Primary Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Primary on Account
Name: Last, First MI
Relationship to Insured:
City: State: Zip:
Phone Number:

Privacy And Payment Policy


Our practice is committed to educating our patients about healthcare issues that affect them. As a result, we are providing you with general information about the Privacy Ruler, a federal regulation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) along with a brief overview of our Notice of Privacy. We are complying with the HIPPA's regulations.

What is HIPPA and how does the Privacy Rule affect you?

When the Health Insurance Portability and Accountability Act (HIPPA) was passed in August 1996 this gave the federal government the ability to mandate how healthcare plans, providers and agencies send a patient's personal information as it relates to healthcare. The Privacy Rule was created to protect your rights as a patient of our practice and we are required by law to be compliant with this regulation on April 14, 2003. Under this rule you are guaranteed access to your medical records, allowed control over how your protected health information is used and disclosed and allowed to take action if your privacy is compromised by following the practice's policy. Our practice is dedicated to maintaining the privacy of your personal information.

What is Individually Identifiable Health Information (IIHI)?

Any health information you provide our practice, including your mailing address. Information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment and/or that identifies you as an individual.

What is the Notice of Privacy Practice (NPP)?

Our practice has an official Notice of Privacy Practice (NPP) posted in our waiting room informing our patients about their rights surrounding the protection of your IIHI and our obligations concerning the use and disclosure of your IIHI. This notice applies to all records created or retained by our practice. We can update our Notice Privacy Practices at any time. It will be posted in our waiting room and you can ask for a copy of the current notice at any time.

The following categories describe the different ways in which we may use and disclose your IIHI:

Treatment Payment Appointment Reminders Release of Information to Referring Sources * Treatment Options Disclosures Required by Law Health Care Operations * Health Related Benefits and Services Hearing Aid Companies
The following categories describe unique situations in which we may use or disclose your IHII:
Public Health Risks * Health Oversight Activities * Lawsuits and Similar Proceedings * Law Enforcement * Deceased Patients * Workers Compensation * Serious Threats to Health and Safety Research * Military National security * Inmates * Organ and Tissue Donation

What are your rights concerning your Individually Identifiable Health Information (IIHI)?

You have rights regarding the IIHI that we maintain about you. In our Notice of Privacy you can view the policies and procedures you will need to follow for the areas listed below.

1. Confidential Communications
2. Requesting Restrictions
3. Inspection and Copies
4. Amendment
5. Accounting of Disclosures
6. Right to a Paper Copy of this Notice
7. Right to File a Complaint
8. Right to Provide an Authorization for Other Uses and Disclosures

If you have any questions regarding this notice or our health information privacy policies, please contact: Peter Charron, OD of Northwest Vision Development Center: 1616 Cornwall Ave Ste. 105 Bellingham, WA 98225 ______________________________________________________________________________________________________________________________________________________


Our goal at the Northwest Vision Development Center is to provide the best vision care service and products that satisfy our patients' needs at a reasonable price.

FULL PAYMENT FOR PROFESSIONAL SERVICES AND/OR MATERIALS IS DUE AT TIME OF SERVICE. Acceptable forms of payment include cash, personal check, Visa, Mastercard & debit cards. A $30 FEE WILL BE CHARGED FOR NSF CHECKS.

What if I have insurance?


There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and NW Vision Development Center may accept plans in both categories.

Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis and management or treatment of eye health problems.

Medical insurance must be used for medical eye care, including therapy and rehabilitation.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and some services to the other.

Please provide your insurance cards to our staff member so we can make a copy. We need to have your medical insurance on file for future billings to your insurance.

Our clinic is contracted with a variety of insurance networks. All insurance eligibility must be presented and confirmed prior to the services. If eligibility for services cannot be verified, you will be responsible for payment in full for all services and materials at the time of your visit. All fees are the full responsibility of the patient/parent/guardian. If our office is contracted with your insurance, our office will file an insurance claim (HCFA 1500) on your behalf. However, it is your responsibility to pay in full for any services or materials not covered by your insurance plan. If you prepay for any service or materials, any insurance payments we receive at a later date will be credited to your account and/or refunded to you. If there are fees which are not collected on the date of service and are not paid by your insurance, we will bill you for them, such as deductibles, co-pays or non-covered services. Insurance codes for pre-determination of benefits will be supplied upon request.

Eyeglass and Contact Lens Return Policy:

Eyeglass Rx Changes:

Progressive Addition Lens Non-Adapt Policy:

Policy for Making New Lenses for a Patient's Old Frame:

***It is understood that the Northwest Vision Development Center reserves the right to send to collections any account when lack of effort to satisfy unpaid balance(s) is shown. It is understood that should it become necessary for my account to be turned over for collections, I will be liable for any and all resulting collections and/or legal fees incurred. It is understood that failure on my part to adhere to this payment agreement will result in a break from treatment.

I acknowledge that I have read and received a copy of the foregoing agreement. I consent to treatment and I assume all financial responsibility for all treatment expenses.

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