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
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Widowed
Employer / School Name
Misc/Guardian
Billing Information
Is The Billing Address Different?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Medical History
Reason for Visit:
Primary Reason:
History of Present Illness:
Do you currently have any of these symptoms?:
None
Itching
Burning, Stinging
Red
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Have you had any eye surgeries? Please describe:
Last Eye Exam:
1 year
2 years
3 years
Other
Last Appointment Type
By Doctor:
Primary Vision Correction:
None
Prescription Glasses
Prescription Reading Glasses
Soft Contacts
Non-Prescription Reading Glasses
Other
Intrested in Eyelid cleaning?
Intrested in Ortho-K?
Intrested in Contact Lenses?
Intrested in Glasses?
Intrested in Medical Procedures(Select below)?
Medical Procedures:
None
Glaucoma Testing
Cataract Evaluation
Dry Eye Treatments
Diabetic Eye Exam
Plaquenil Testing
Macular Degeneration Evaluation
Other
Medications
Medications:
No Meds Used
Drug Allergies:
No Known Drug Allergies
Primary Care Physician:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason:
Check up
Annual
Specific
Other
Acknowledgment of Notice of Privacy Practices
Click here to read the full Privacy Policy
The law requires that DeNovo Eye make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:
I was given the opportunity to read, have read or had explained to me DeNovo Eye's Notice of Privacy Practice prior to any services offered.
The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible
I authorize DeNovo Eye to release my personal health information to the following individuals:
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
Patient Signature:
Date:
If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor
Representative Signature:
Relationship to Patient:
Financial Disclosure
I understand that
vision plans
(VSP, EyeMed, etc) are
NOT
medical insurances and therefore only cover routine vision services
I understand vision plans do
NOT
cover or contribute to chronic management or treatment of ocular disease, medical procedures, or specialized testing
I understand that
medical insurance
will be necessary to cover or contribute to medical diagnoses, management or treatment of ocular disease, or other medical procedures
I understand that in order to maximize my usage of benefits, DeNovo Eye requires all patients to present
both
medical insurance and vision plan information at the time of scheduling appointment
DeNovo Eye requests that all professional services, material charges, and fees be paid at the time services are rendered by the patient unless other written arrangements are made in advance
The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance coverage
Custom eyewear measurements performed by our trained opticians, including pupillary distance (PD), are included at no cost when purchasing eyewear through our office. We do provide this service for
$45.00
for eyewear purchased outside our office
Unpaid accounts exceeding
90 days
are subject to collection fees
There will be a service charge of
$30.00
on all returned checks
Missed appointments without a courtesy 24-hour notice will incur a charge of
$45.00
Maestro Retinal Imaging
=
$45.00
This is an out-of-pocket expense not covered by Vision Plans
This test is part of our comprehensive eye exam to establish an ocular health baseline for ALL of our patients, and is part of our
standard of care
I understand this test is
NOT OPTIONAL
as per our office policy and will be performed on every comprehensive exam
I understand that this is Non-Covered Service by any Vision Plan (VSP/Eyemed) and therefore is NOT included with "routine exam" copays
Routine dilation will be performed in
addition
to this test as per the discretion of the doctor for each individual case based on medical necessity
Your doctor will carefully review any findings or abnormalities during your exam
The undersigned will ultimately be responsible for any remaining balance after insurance coverage has been applied.
I hereby understand and fully agree with the above office policies, charges, and protocols
Patient Signature:
Date:
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