Patient Pre-Visit Form

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

No Yes

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!

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 certify that upon entering Specs Appeal that I/we are Covid-free, and have not experienced at 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
Should be Empty:

Help make your visit clean and efficient by filling/modifying this Pre-Visit Form before your Eye Exam. ***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.***