Please take a minute to fill out our new patient information form. The information you enter on this page is submitted to a secure site and will be kept completely confidential.
Due to Federal Guidelines, hospitals and eligible professionals are now required to provide information regarding the race and ethnicity of their patient population. We are asking that you assist us in providing this information by making the most appropriate selection regarding race and ethnicity from the following choices.
Vision Insurance Information
*This information will help us verify coverage for your annual eye exam, eyewear, or contact lenses*
Medical Insurance Information
*This information may be needed in the event there is a medical finding during your exam, such as diabetes, glaucoma, macular degeneration, eye infection, etc*
Review of Systems: Please indicate if you are CURRENTLY experiencing any of the following:
Optomap Digital Imaging
Optomap is a non-dilated technology that uses a safe scanning laser tocreate an image of the inside of the eye. This technology allows us todocument the internal structures of the eye and detect over 100 differenteye diseases such as retinal detachments, diabetic retinopathy, glaucoma,macular degeneration, and retinal changes due to high blood pressure andcholesterol.
Dr. Cole and Dr. Dodd strongly recommend images be taken each year onall patients, no matter the age, to monitor for any changes. Once theimage is taken, it will be reviewed with you by the doctor in the examinationroom.
Click here http://optomap.com/en-US/ for more in-depth information about Optomap.
The procedure is quick and simple! It is not covered by most insurancecompanies, as they do not cover screenings. We offer the digital imagingfor $33 on the day of your examination.
Consent For Dilation *If recommended by doctor*
Many Diseases such as diabetes, hypertension, glaucoma and tumors of the eye, as well as tears and holes in the retina, can be detected with dilation. Dilation requires placing drops in the eyes to enlarge the pupil which allows a thorough examination of the inside of the eye for these and other problems. The side effects can be blurred vision and light sensitivity for about 2-4 hours. There is no additional charge for this procedure.
HIPAA Privacy Consent
To Our Patients:
Federal law requires that we provide you with a copy of our Privacy Notice.
The Privacy Notice explains how we may use and disclose health information about you. We ask that you sign this form for our records so that we may document your receipt of the Notice.
If you have questions about the Privacy Notice, please feel free to direct these to our Privacy Officer at any time. The name and contact number of the Privacy Officer is listed on your copy of the Privacy Notice.
Consent to Disclose Information
We understand that there may come a time where a family member, friend, or other, will need to speak with us on your behalf. This may include, but is not limited to, appointment details, financial information, personal health information, etc. Please list the information of any person that may contact us on your behalf, as consent for us to speak with them. You may also notate Declined Access for certain individuals.
*A blank form will indicate that you have chosen to Decline Consent for Release of Information.
Professional fees are due upon completion of services. Although we do bill most insurances, please be advised that payment is still your responsibility. For your convenience, we accept Visa, Mastercard, Discover, personal check and cash. Please note that all returned checks are subject to a $40 charge.