Online Patient Forms

Patient information

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Billing information

If yes, please provide the billing address information below

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

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Eye History

Contact Lens Wearers only:

Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?







Family Eye History

Does anyone in your family have any of these eye conditions?







Review Of Systems














Social History

Policies, Consent, Submit Data


NOTICE OF PRIVACY PRACTICES
Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View Bowersox Vision Center, PSC Practice Policies Form

Medicare and some other carriers do not pay for refraction. There will be a $40 to $50 (complex) fee for refraction if your insurance does not cover refraction. Refraction is the part of the exam where your glasses or contact lens power is determined.
Check this box if you would like to not have this part of the exam done.

Bowersox Vision Center (BVC) will contact you using the phone number you provided. Unless you indicate otherwise, your spouse may receive medical information from this office about you. You agree to receive communications concerning your visit / treatment / account / notification that materials are ready for pick-up
Check this box if you do not want to be contacted with the phone number provided.

Check this box if you do not want your medical information discussed with your spouse.

I acknowledge that I am responsible for any amounts not covered by my insurance & have been made aware of the Appointment Policy. I understand the information above and have had the opportunity to ask questions to my satisfaction.

Signature: Date: