New Patient Registration

Prefix

Last Name*

First Name*

Middle Initial (optional)

Preferred Name*

Address*

Home No.

Cell No.*

Work No.

Email*

Best Way to Contact:

Emergency Contact/relationship (Optional)

Phone Number

Employer/School

Patient SSN#

Date of Birth

Gender

(if a Minor) Parent's Name

Spouse's Name

Are You: (Optional)

Who May We Thank for Referring You to Our Office? (Optional)

Where did you find us?

Date

Vision Plan Information

Vision Plan

Subscriber Ssn/id#*

Subscriber Name:

Subscriber Birth Date:

Relationship to Patient:

Medical Insurance Information

Primary Medical Insurance

Subscriber Ssn/id#

Subscriber Name:

Subscriber Birth Date:

Secondary Medical Insurance?

Secondary Medical Insurance?

Subscriber Ssn/id#

Subscriber Name:

Subscriber Birth Date:

Medical Insurance

Lifestyle Questions (check all that apply)

Contact Lens Info:

Do you wear contact lenses?

Type/brand

Financial Information

In order to control the cost of billing, we ask that the patient’s portion is paid at the time services are rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge of $25 on all returned checks. Payment from my vision plan/medical insurance is to be paid directly to Clearfinity Eyecare Optometrist and I understand that (name of vision plan or medical insurance)

will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made once the claim is processed. All eyewear purchases are final sale and only a store credit can be issued that can be used for any future eyewear purchases.

Privacy Practices

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree you are bound to abide by such restrictions.

Date*

Patient Name:*

Patient Medical History

Family Physician:

Address:

Last Physical Check-up:

Current Medications (Prescription or Over-the-counter)

Allergies to Medicines?

If so, What Medications?

Do You Use Cigars/ Cigarettes/ Tobacco?

Do You Drink Alcohol?

Do You Use Recreational Substances?


Have You Ever Been Diagnosed or Treated for the Following?

Allergies

Arthritis

Sickle Cell

Bronchitis

Cancer

Cholesterol

Diabetes

Digestive

Autism

Multiple Sclerosis

Eczema/Rashes

ADHD

Vascular Disease/Stroke

Heart Disease

High Blood Pressure

Seizures

Kidney disease/Stone

Autoimmune Disease

Migraines

Psychiatric

Asthma/Lung disease

Sinus/Throat Infections

Thyroid Disease

Unusual weight losses/gains

Patient Name

Patient Eye History

Date of Last Eye Exam:

By Whom?

Have you had any eye-related surgeries of any kind?

What Are the Main Reason (S) for Your Visit? (check all that apply)

Check Eye Conditions That You Have Been Diagnosed:

Family Medical History (check all that apply)

About Your Vision Plan/medical Insurance

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts one or both:

  • Vision Care Plans (such as VSP, Davis, Eyemed etc..)

  • Medical Insurance (such as Blue Cross/Blue Shield and United Health Care etc..)

  • Vision care plans ONLY cover ROUTINE vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They DO NOT cover diagnosis, management, or treatment of eye diseases, dry eye, itchy eyes, cataracts etc...

  • Medical insurance MUST be used if you have any eye health problem or systemic health problem that has ocular complications. (e.g. dry eye, red eye, eye pain, itchy eyes, discharge from eyes etc..) Your doctor will determine if these conditions apply to you, but some are determined by your case history or reason for your visit.

  • If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

  • We will bill your insurance plan for services if you we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract.

Check to confirm:

Date:

Appointment Policy

If you are unable to keep a scheduled eye exam appointment, we ask that you please give us at least 24hrs notice. "Late Cancellation" or "No Show" appointments may be charged $40 on weekdays and $50 on Saturdays.

Check to confirm:

Contact Lens Evaluation Fee

According to the FDA, all contact lenses are considered a MEDICAL DEVICES, since they are inserted directly on your eyes. Therefore, every year, if you want to purchase contacts or get a prescription for them, even if your prescription does not change, you must get a new evaluation for eye health purposes. This fee is separate from your regular exam that includes your eyeglass prescription and is inclusive of all contact lens trial lens follow up visits within 2 months or 60 days from your initial exam or when your contacts are finalized, whichever is first. Depending on the complexity of your prescription, the type of contact lens therapy, and your insurance coverage if applicable, this NON-REFUNDABLE fee can range from $149 and up.

Please check the box and sign below if you need your annual contact lens evaluation/prescription and agree to this fee:
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Visual Screening/Retinal Imaging

At Clearfinity Eyecare Optometrist, Dr. Laura Frederick believes in providing a yearly complete comprehensive eye examination, which can result in early detection of potential vision threatening and even life threatening diseases that are not just limited to the eye.

We currently have a state-of-the-art Visual Field diagnostic device which is helpful in diagnosing any potential issues that occur between the eye and the brain beyond what we can see in a dilated eye exam.

The Visual Field diagnostic device tests different points of your peripheral (side) vision. Any cluster of defects found in the screening may signify a neurological concern.

The most common issue that can be detected very early with a Visual Field Screening is Glaucoma.

Glaucoma is a painless, slow eye disease that causes the death of optic nerve fibers resulting in gradual loss of peripheral vision over time. There is a much higher risk if an immediate family member has it.

The cost of the Screening Visual Field is $29.

A Wellness Retinal Imaging procedure is an additional screening tool that involves capturing an image of the back central part (retina) of your eyes. This is not an x-ray or ultrasound procedure and will not touch your eye. This permanent record is very valuable in assessing the current health of your eye. It also serves as an initial baseline from which to compare as we follow your eye health in subsequent years.

The cost of the Wellness Retinal Imaging is $35

Since these are screening tests, medical and vision plans will not cover it, however any abnormalities that are detected in the screening assessment will result in you returning to the office for a more extensive medical visual field test/retinal imaging that can be billed to your medical insurance minus any contracted co-pays.

Together, both screenings provide a complete documented assessment of all the appearance and function of your retina. If you choose to have both screenings done it will be packaged at $59 – a $5 savings.

Please place Check one of the following