Patient Pre-Visit Form

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.

Would you like to be evaluated (i.e., get a Prescription) for Contact Lenses as part of this exam? *

No Yes

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!

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 a $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
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Help make your visit clean and efficient by filling out this Pre-Visit Form before your Annual Wellness Eye Exam.

Contact lens prescriptions are uploaded to the Patient Portal once finalized. Printed copies are available from the front desk upon request.