Welcome to Orlando Eyecare

Patient Information

Today's Date:

01/01/2001

Patient's Name:

Addresss:

City:

Zip:

Home Phone:

123-456-7890

Work Phone:

123-456-7890

Cell Phone:

123-456-7890

Email Address:

Date of Birth:

01/01/2001

Last 4 of Social Security #

Last (4) 1234

Sex:

Employer or School:

Occupation or Grade:

Spouse or Parent Name:

If patient is a minor, who is responsible for payment of the bill?

Referrals are our greatest compliment. We enjoy thanking referrers with a gift card to Starbucks, Wawa or AMC.

Whom may we thank for referring you to our office?

Please let any friends, family or co-workers you refer in let us know your name!

Insurance Information

Vision Insurance:

Medical Insurance:

Policy Holder's Name:

Policy Holder's Date of Birth:

01/01/2001

Main reason for your visit?

Do you wear contacts?

If “Yes”, our goal is all day comfort with your contacts. What would you describe as your comfort level?

Do you wear reading glasses? Play sports? Don’t always want to wear glasses? Contacts may be a perfect fit for your lifestyle. Great advances have been made in areas of both comfort and vision, including “multi-focal” contacts, these are contacts worn for both near and far visual needs – we can discuss this option today.

Medical History

Glaucoma - Self

Glaucoma - Blood Relative

Diabetes - Self

Diabetes - Blood Relative

High Cholesterol - Self

High Cholesterol - Blood Relative

Thyroid - Self

Thyroid - Blood Relative

Cataracts - Self

Cataracts - Blood Relative

High Blood Pressure - Self

High Blood Pressure - Blood Relative

Headaches

Itchy Eyes

Redness

Dry Eyes

Excessive Tears

Light Sensitivity

Do you smoke?

Do you drink alcohol?

If yes, how often do you drink?

Any major surgery or illness?

Are you allergic to any medications?

List any medications you are taking:

I authorize Orlando Eyecare to file a claim for today’s visit with my insurance company, if appropriate. If so, I will be responsible for all charges that are not covered or paid by my policy. I am aware that the contact lens fitting and follow up care may not be covered under the “exam” definition of my policy.

Signature of Patient / Responsible Party:

By typing my name in the box below I am offering my digital signature in lieu of my handwritten signature. I understand that my digital signature carries the same legal bindings as my handwritten signature.

Date:

01/01/2001

Please read and initial at the end of each statement…

Orlando Eyecare Financial Policy

Thank you for choosing Orlando Eyecare as your eye care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment plan. The following statements in regards to our Financial Policy are required to be read and signed prior to any treatment.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE.
WE ACCEPT: CASH, CHECKS, VISA, MASTERCARD,
DISCOVER AND CARE CREDIT.

Regarding Insurance

We will file your insurance as a courtesy to you, but if no payment has been made from your insurance company within 60 days, the current balance remaining becomes the responsibility of you, the patient (or guarantor). The balance is your responsibility whether your insurance company pays a portion or not. We cannot bill your insurance company unless you give us your correct insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party in that contract. Please be aware that some, perhaps all, of the services provide may be non-covered services and not considered reasonable and necessary under Medicare and /or other medical insurance.

Initials (Regarding Insurance)

Usual & Customary Rates

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Initials (Usual & Customary Rates)

Minor Patients

The adult accompanying a minor and the parents (or guardian of the minor) are responsible for payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit card, or payment made by cash or check and the time of the visit.

Initials (Minor Patients)

Thank you for reading our Financial Policy. Please let us know if you have any questions or concerns. I have read the Orlando Eyecare Financial Policy and I understand and agree to the terms.

Signature of Patient/Responsible Party:

Date (Patient/Responsible Party):

01/01/2001

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