Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Sign Here if filling out this form for a minor

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Vision Insurance

Insurance Information

Insurance Name:

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Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

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Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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

Eye History

What is the main reason for your visit today?

Do you currently have any of these symptoms?

Do you currently take any of these eye medications?

Please list any eye surgeries and/or trauma (include dates)

Last Eye Exam

By Doctor

Ophthalmologist

Last Visit

Primary Vision Correction

What type of glasses do you wear?

How old are your glasses?

Do you wear contacts?

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Contact Lens Wearers Only

What solution do you use?

Do you have backup glasses?

How often do you sleep in your contacts?

How often do you replace your contacts?

Family Eye History

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

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Medical History:

Medications No Medications

Drug Allergies No known drug allergies

Vitamins

Over the Counter Medications

Please describe any injuries or surgeries you have had:

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Do you have any of these medical conditions?

Diabetes

Year Diabetes Diagnosed

HbA1c

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Family Medical History

Unknown family history

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

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

STDs

Policies, Consent, Submit Data

Patient Responsibility

I understand and agree that I am financially responsible for all charges for any and all services rendered. This includes any medical service or visit, routine examination, refraction, testing, contact lens services and any other screening ordered by the doctor or staff.

I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.

I understand and agree that it is my responsibility to know if my insurance has any deductible, copayment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the services I receive and I agree to make payment in full.

I understand and agree that it is my responsibility to know if my insurance requires a referral from my primary care physician and that it is up to me to obtain the referral. I understand that without this referral, my insurance will not pay for any services and that I will be financially responsible for all services rendered.

I agree to inform the office of any changes in my insurance coverage. If my insurance has changed or is terminated at the time of service, I agree that I am financially responsible for the balance in full.

If I am a Medicare patient, I understand that I need to provide the office both my Medicare ID card and my secondary ID card. If the office does not have the proper information for a secondary insurance, the secondary will not be billed. It will be my responsibility to pay the balance and then file a claim with the secondary for reimbursement.

By signing this form, I consent to the use and disclosure of protected health information about me for treatment, payment and health care operations, and/or as required by law. I have the right to revoke this Consent, in writing, signed by me. However, such revocation shall not affect any disclosures already made in compliance with my prior Consent. Blackwelder Optometry provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Patient Signature

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Date

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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 the legal authority to make medical decisions for the minor and consent to such care. Please indicate any other parent, step-parent, guardian or other individual(s) authorized to make medical decisions for the minor.

Representative Signature

Relationship to Patient

Other individuals authorized to make legal decisions for the minor

I give permission to communicate my Private Healthcare Information to:

Name

Relationship

Name

Relationship

Our office does not make the rules. They are determined by your specific medical insurance or vision plan.

I acknowledge that Vibe Optometry requires Optos retinal imaging for all comprehensive eye exams. I have been notified of the $39 copay for this imaging that is not covered by insurance.

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RETURN POLICY FOR EYEWEAR & CONTACT LENSES

Eyeglasses are custom-made for you and you only, so there are no returns for any purchased eyewear (including lenses and frames). Even though all sales of prescription and non-prescription eyeglasses and sunglasses are final, patients are welcome to return to the office as many times as needed before the decision to purchase is made. If there is a need for the prescription to be adjusted, such lens changes are included at no charge for a one-time redo within 60 days from the date of exam. If there are any discrepancies between the doctor's prescription and the lenses manufactured by the lab, these changes will be made at no charge. For any issues with a prescription, the patient must notify the office within 60 days of the exam for a free, one-time glasses prescription check. Outside of 60 days, a $50 prescription recheck fee will be charged. All of our lenses & frames have a warranty for any manufacturer defects for up to one year from the date of purchase, which does not include accidental damage, from for example, dropping your eyewear. For any frame exchange, the frame must be exchanged within 30 days and in perfect condition. There is a $50 restocking fee plus a charge for any difference in frame cost.

CONTACT LENS EXAMINATIONS

Upon completion of a contact lens fitting, all patients will be dispensed a trial pair of contact lenses. This is a free trial for the patient to determine if the vision and comfort of the lens is acceptable to purchase. Patients have 30 days from the start of the trial period to return to the office and make adjustments to their contact lens brand or prescription. After 30 days, a $50 refit fee will be charged for any changes made outside the trial period and before the patient's next annual comprehensive examination. With regard to the sale of non-specialty soft contact lenses, any unopened & unmarked boxes may be exchanged within 60 days if there has been a change to your prescription.

PICKING UP EYEGLASSES & CONTACT LENSES

All eyeglasses and contact lenses that have been prescribed, fitted, and purchased by the patient will be kept in the office for a total of one year from the date of purchase. If the patient does not pick up his/her eyeglasses or contact lenses within that year, we will subsequently donate them to charity.

I acknowledge Vibe Optometry optical policies.

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