New Patient Forms For faster service, please complete the following form prior to arriving at our office.Appointment Date MM slash DD slash YYYY Is this for a child? Yes Patient’s Name First Middle Last Gender Male Female Social Security Number Parent’s Name First Middle Last Employer Occupation Spouse’s Employer Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneEmail How did you find out about our office? Internet Search Doctor's Referral Friend Who referred you? Do you have insurance? Medical Vision Please bring all insurance cards with you to your appointment. Medical InsuranceInsurance Company Name Insurance Company Phone Number Insured's Name First Last Identification Number Group Number Insured's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured Vision InsuranceInsurance Company Name Insurance Company Phone Number Insured's Name First Last Identification Number Group Number Insured's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured Personal Medical InformationDo you have problems with any of these systems?If Yes, please check box. Gastrointestinal Nervous System Mental Ear/Nose/Throat Genitourinary Endocrine (Glands) Cardiovascular Musculoskeletal Blood/Lymph Respiratory Skin Allergic/Immunologic Headaches Surgeries (what type & when) Are you in good health? Yes Any allergic reactions to medications or other substances? Yes please list Name of general physician Do you smoke? Yes how much? Do you drink alcohol? Yes how much? Do you take medications? Yes Please list names & how often Do you use other substances? Yes 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 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.SignatureDate MM slash DD slash YYYY 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 on services, custom made contact lenses and glasses. In some cases exchanges can be made within 30 days of receipt. All custom contact lenses have a re-stocking fee. Forms & Reports: There is a $5 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. SignatureDate MM slash DD slash YYYY
