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Help make your visit clean and efficient by filling/modifying this Pre-Visit Form before your examination. ***Note: This only has to be filled out again if ANY information has changed since the last time the patient was at our office, e.g., demographics, medical history, insurances, etc.***
How did you Primarily hear about us?
Family comes here too!
Search engine (Google, Bing, etc.)
Social Media (Facebook, Instagram, etc.)
Recommendation from a Friend/Colleague
My vision plan/insurance
Driving/walking by
L.C.A. referral
Patient's Name
*
Mr.
Mrs.
Ms.
Prof.
Dr.
Rev.
Title
First Name
Last Name
Middle Inital or Nickname (TYPE NONE for no middle or nickname)
Patient's Birth Date
*
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Mobile Phone Number: This will be used to send text messages such as appointment reminders, order status, and pickup notifications.
*
-
Area Code
Phone Number
Email Address: Please be precise as your "Patient Portal" will be linked to this email. You should receive a confirmatory email after this form is completed.
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Any past Truama or Surgeries to Patient's Eyes?
*
No
Yes
List any past trauma or surgeries to the Eyes:
*
Any Family history of Eye diseases or blindness?
*
No
Yes
List any Family member followed by their eye disease(s), or what they went blind from.:
*
Is the Patient currently taking any medications, supplements, or vitamins?
*
No
Yes
List any medications, supplements, or vitamins currently being taken:
*
Is the Patient Allergic to any Medications?
*
No
Yes
List any Medication allergies:
*
Please upload or take a Zoomed-in-Photo of the front of your Drivers License (or legal ID). If the patient is a Minor, then a photo of the face will suffice.
Are you planning to use Medical Insurance or a Vision subsidy plan for this visit?
*
No
Yes
Primary Insured's Social Security Number for insurance purposes only. If the patient is not the Primary, then please add Name and Birthdate on a separate line.
*
If you have a VISION plan card, please upload or take a Zoomed-in-Photo of the card.
If you have MEDICAL Insurance, please upload or take a Zoomed-in-Photo of the FRONT of the card.
If you have MEDICAL Insurance, please upload or take a Zoomed-in-Photo of BACK of the the card.
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Please accept that you read and understood the above to continue:
Accept
Financial, Hipaa, and Privacy Notices
Please accept that you read and understood the above to continue:
*
Accept
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Would you like to be evaluated (i.e., get a Prescription) for Contact Lenses as part of this exam?
*
No
Yes
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Contact Lens wearer T&C
*
Contact lens prescriptions are uploaded to the Patient Portal once finalized. Printed copies are available from the front desk upon request.
Thank you for helping us stay green!
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As part of the state-of-the-art Annual eye health examinations at Specs Appeal, I consent to having the the Retina Imaging and Retina Scans (see videos below for better understanding). I understand there is a $39 copay for these tests unless covered in part or full by my insurance/vision plan. *Note: this may not apply for Medical visits or if Medical insurance is being used.
*
I Accept
Optomap Retinal Imaging
iWellness Retina Scans
Sign below acknowledging and consenting to using the secured Patient Portal (to access all receipts, prescription, etc. that you might want); correspondences via use of any electronic means like emails and text messages; as well as reading/understanding and consenting to the above fees, financial, and privacy disclosures on an annual basis. I understand that it is my responsibility to update and let the office know if any personal information (demographics, insurances, etc.) changes at any time.
*
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