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Help make your visit clean and efficient by filling out this Pre-Visit Form before your Annual Wellness Eye Exam.
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. specific referral
I'm a current patient.
Patient's Name
*
Mr.
Ms.
Mrs.
She/Her
He/Him
They/Them
Prof.
Rev.
Dr.
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
Back
Next
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.
Back
Next
Would you like to be evaluated (i.e., get a Prescription) for Contact Lenses as part of this exam?
*
No
Yes
Back
Next
Contact Lens wearer Terms & Resposibilities.
*
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!
Back
Next
Financial, Hipaa, and Privacy Notices
Please accept that you read and understood the above to continue:
*
Accept
Please accept that you read and understood the above to continue:
Accept
As part of the state-of-the-art Annual eye health examinations at Specs Appeal, I consent to having the the Topography/Tomography, Axial Biometry, and/or Retina Imaging/Scans (see videos below for better understanding of the Retina ones). I understand there is an additional $59 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
Youtube
Youtube
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 certify that upon entering Specs Appeal that I/we are Covid-free, and have not experienced any Covid symptoms (e.g., fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) for at least 10 days before my visit at this office. I understand that it is my responsibility to update and let the office know if any personal information (health, demographics, insurances, etc.) changes at any time.
*
Clear
Submit
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