• Patient Demographic Form

  • Personal Information

  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  • Contact Information

  •  -
  •  -
  •  -
  • Guardian/Responsible Party Information

  •  -
  • Emergency Contact

  •  -
  • Privacy Policies and Consent Forms

  • Notice of Privacy Practices and HIPAA Agreements

  • Office Policies

  • St. Lucy's Vision Center Finance Agreement

  • Insurance Information

  • Vision Insurance

    Though often provided in conjunction with medical health insurance plans, vision plans generally are managed through a separate insurance company (e.g Vision Service Plan, VSP, Eyemed). These plans provide discounts and benefits towards routine eye exams, glasses and contact lenses, but not for medical eye issues such as disease, infections or injuries. For most patients, the vision insurance company managing these benefits is not the same as their health insurance company.
  •  -  -
    Pick a Date
  • Medical Insurance

    Medical insurance can be used within our practice for the treatment and management of eye diseases, infections, injuries and other non-routine services. We encourage all our patients to provide this information even if you are scheduled only for your routine eye exam. Having this information on file will allow us to manage, treat, or refer to other providers for medical issues should any arise during your visit. Claims will never be sent to your medical insurance without your consent.
  •  -  -
    Pick a Date
  • Secondary Medical Insurance

  •  -  -
    Pick a Date
  • Should be Empty: