For faster service, please complete the following form prior to arriving at our office.

Appointment Date*

Is this for a child?*

Yes
No

Patient’s Name*

First Middle Last

Date of Birth*

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Date of Birth*

Gender

Male
Female

Social Security Number*

Parent’s Name*

First Middle Last

Employer

Occupation

Spouse’s Employer

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Email*

How did you find out about our office?*

Internet Search
Doctor's Referral
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Who referred you?*

Do you have insurance?

Medical
Vision

Please bring all insurance cards with you to your appointment.

Medical Insurance

Insurance Company Name*

Insurance Company Phone Number*

Insured's Name*

First Last

Identification Number

Group Number*

Insured's Date of Birth*

Patient's Relation to Insured*

Vision Insurance

Insurance Company Name*

Insurance Company Phone Number*

Insured's Name*

First Last

Identification Number*

Group Number*

Insured's Date of Birth*

Patient's Relation to Insured*

Personal Medical Information

Do you have problems with any of these systems?

If Yes, please check box.

Surgeries (what type & when)

Are you in good health?*

Yes
No

Any allergic reactions to medications or other substances?*

Yes
No

please list*

Name of general physician*

Do you smoke?*

Yes
No

how much?*

Do you drink alcohol?*

Yes
No

how much?*

Do you take medications?*

Yes
No

Please list names & how often*

Do you use other substances?*

Yes
No

Do you have family history of any of the following? If Yes, please check box.

Diabetes
Glaucoma
High blood pressure
Macular Degen
Retinal Detachmt
Cataracts

Please explain any boxes you have checked

Do you have any of the following? If Yes, please check box.

Dry Eyes
Eye Surgeries
Wear Glasses
Blurred Vision
Eye Injuries
Wear Contacts

Any eye problems at this time? Please explain

Are you interested in laser vision correction?*

Yes
No

Please sign below that:

1. I have reviewed all information above and it is correct to the best of my knowledge.

2. I authorize the release of any medical information necessary to provide the most beneficial and complete visual examination. I understand that I am financially responsible for all charges whether or not paid by insurance. Payment is due at the time services are rendered.

Signature*

Date*

Please sign below that:

I have read the Office Policy & Fee Disclosure.
I have read the Privacy Policy found by clicking here.

Office Policy & Fee Disclosure
Thank you for choosing EyeSymmetry Vision Center. Please read over our office policy and sign in the space provided. If you have any questions, please don't hesitate to ask.

Insurance: All co-pay and deductibles must be paid for at the time of service. This arrangement is part of the contractual agreement with your insurance company. Please also keep in mind that it is your responsibility to know your insurance benefits, and while we try to provide you with accurate information, it is not guaranteed.
Referrals: It is your responsibility to know if a referral is required by your insurance company. If you do not have a referral at the time of your visit you will be required to sign a Referral Waiver. You will be responsible for the full payment of the services provided if it is not received within 5 business days.
Payments: We accept cash, money orders, all major credit cards and checks under $50.00. A $30.00 fee will be charged if a check is returned.
Missed Appointments: Advance notification is required if you are unable to keep your appointment. A $25 fee will be charged for all no shows. No exceptions.
Contact Lens Evaluation: Whether you are a first time or existing contact lens wearer, this service is not part of the comprehensive eye exam. The fee for this service varies on the condition of your eye, type of lenses and, if applicable, your insurance plan.
Refund Policy: There are no refunds.
Forms & Reports: There is a $15 charge for MVA and failed school screening forms that are NOT presented at the time of exam. All other forms and reports have a charge of $10.00 and up.