Online Patient Form

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

Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address The Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary Vision

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

Secondary Vision

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

Primary Medical

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

Secondary Medical

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

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Reason for Visit:
Primary Reasons: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Family Medical History



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

Diabetes:
YrDx                      HBA1C
High Blood Pressure:
Thyroid Conditions:
High Cholesterol:
Heart Conditions:
Cancer:

Family Eye History

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

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:
STD

Submit Form / Patient Signatures



Receipt of Notice of Privacy Policies & Consent Form

In the course of providing service to you, we create, receive, and store health information for treatment purposes. This includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health care professional. You are free to refer to The Notice of Privacy Practices at any time before signing this form which describes the uses and disclosures in detail. Similarly, the use and disclosure of your health information for purpose of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment: (2) our submission of claims to third-party payers or insurers for claim review, determination of benefits and payment: (3) our submission of your health information to auditors hired by third-party payers and insurers: and (4) other aspects of payment described in your Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get a updated copy here at the office.

When you sign this document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and to perform health care operations.

You have the right to ask us to restrict the uses of disclosures made for purposes and treatment payment or health care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I have read this document and understand it. I consent to the use and disclosure of my health information for purpose of treatment, payment, and health care operations. I acknowledge that I understand the Notice of Privacy Policies.

Signature: Date:

If signing as a personal representative of this patient, describe the relationship to the patient and the source of authority to sign this form.

Written Financial Policy

Thank you for choosing Daynes Optical Express. Our primary mission is to deliver the best and most comprehensive care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options:

       - Cash, Check, Visa, MasterCard, American Express or Discover

       - Care Credit healthcare credit card. Care Credit is the preferred healthcare credit card providing special financing and payment options* for out-of-pocket medical expenses. Ask for details.
       * Subject to credit approval

If payment cannot be made at time of visit, prior arrangements must be made through billing/ office management. Daynes Optical Express charges $25 for returned checks.

Please note:

It is customary to pay for professional services when rendered. However, if you have a medical problem then we will bill your insurance on your behalf. Refraction is a measurement of the lens power necessary to prescribe glasses or other corrective lenses. Most medical insurance plans, including Medicare, do not cover routine refractions or routine eye exams (when no medical eye problem is known or suspected). Medicare, and most other insurance plans, insists that we charge separately for that portion of the examination, since it is not a covered service. You will receive an explanation of benefits from them itemizing your responsibilities. You will be responsible for any co-payments, deductibles or non-covered services as determined by your insurance company.

Vision Plans: Ifyou have a separate plan that covers routine or annual eye examinations and/or glasses, please let us know. Your vision plan may assist you with your eye care needs that are not covered by your medical plan. We will bill your vision plan as above.

In accordance with our contract and withyour insurance provider, we are responsible for collecting, and you are responsible for paying, co-payments after your exam.

If your insurance medical/vision plan has not paid your claim within 45 days or denies claim, you will be billed.

Daynes Optical Express requires a 50% deposit for glasses and balance due at delivery. Full payment is required for contacts lens orders.

A fee of $25.00 is charged for all "No Show" patients who miss or cancel without a 24 hour notice.

If you have any questions, please do not hesitate to ask. We are here to help you get the quality care you want or need.

Patient, Parent or Guardian Signature: Date:

Patient Name (Please Print): Patient DOB:

Authorization to Release

I hereby authorize the individual(s) list ed below to be able to:

*Pick up Glasses/ Contact Lenses, *Printed Spectacle RX/ Contact Lens RX
*Clinical Recor ds *Medication RX
*Schedule and Inquire about appointments

Authorized Persons:

1.
2.
3.

I understand that:
       * This authorization will be effective as long as I am a patient of Daynes Optical.
       * I may revoke this authorization at any time by submitting a written notice t o Daynes Optical
       * Once Daynes Optical has disclosed my health information to the recipient, we cannot guarantee that the recipient will not disclose my health information.

Signature of Patient or Authorized Representative: Date: