New Patient Demographic Form

If you have never worn Contact Lenses before, that requires an Instruction and Removal which we are not performing at this time due to COVID-19 and the increased risk of exposure due to close contact between the Doctor and the Patient for this exam. If you are a New Wearer and need this instruction, we recommend you return to the office at a later date when the risk of exposure has lowered.

If you currently wear contact lenses, please answer the following questions:

History of Your Eyes

Medical History

Retinal Imaging:

We recommend that every patient have an image of their retina on file. This allows the doctor to assess year after year the continued health of your eyes. This procedure consists of capturing an image of the back part of the eye. This is NOT an X-ray or Ultrasound and nothing will touch your eye. This permanent record is very valuable in assessing the current health of your eye and for safeguarding the health of specific structures such as the Retina, Optic Nerve, Macula, and Blood Vessels.

This procedure is not covered by any vision plans and costs $39.

Insurance Disclaimer, Beneficiary Agreement

I understand that my vision provider/medical insurance companies may deny payment for the services received today based on deductibles, co-insurance, and eligibility. If payment is denied, I agree to be personally and fully responsible for payment. I also understand that if my vision provider/medical insurance company does not make payment for services, I will be responsible for any co-payment, deductible, or co-insurance that applies.