Optix Optometry Patient Info Form

Date:

Legal name:

First NameLast Name

Preferred name (if different):

Birth date:

Age:

Gender (required by insurance companies):

Last 4 of SSN (use 0000 for minors or if you do not have an SSN):

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell phone (or home phone if you do not have a cell phone):

E mail:

example@example.com

Marital status:

Are you a student?

Where do you go to school?

Where do you work?

What is your occupation?

Emergency contact:

Emergency contact phone number:

How do you know this person?

Who is responsible for payment / who is the primary insured?

What is their name?

First NameLast Name

Birth date of the primary insured:

Date

What is their relationship to the patient?

Do they live at the same address as you?

What is their address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is their cell or home phone number?

Do you have insurance?

Name of insurance company:

Member #:

Group #:

If possible, attach an image of the front AND back of your health insurance card here:

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Have you been to Optix before?

Name of previous eye doctor:

Approximate date of last eye exam:

Do you wear glasses?

Do you wear contact lenses?

Are you interested in wearing contact lenses?

Have you had LASIK, PRK or RK?

Have you ever had any eye injuries or other eye surgeries?

Briefly describe your eye injury or type of eye surgery:

Check any boxes if you have recently experienced or have been diagnosed with any of the following with your glasses or contact lenses on:

Name of general practitioner or doctor:

Are you adopted and not aware of your family medical history?

Please indicate if you or any blood relatives have been diagnosed with any of the following medical conditions:

ADD or ADHD

Hay fever

Artificial heart valve

Heart condition or pacemaker

High blood pressure

High cholesterol

Stroke

Cancer

Diabetes

Thyroid condition

Blindness

Cataracts

Retinal disease

Glaucoma

Lazy eye or amblyopia

Macular degeneration

Poor color vision

Gastrointestinal condition

HIV or AIDS

Hepatitis

Kidney disease

Currently pregnant

Shingles

Skin condition

Artificial joints

Rheumatoid arthritis or lupus

Autism

Epilepsy

Mental condition

Depression

Asthma

Emphysema or COPD

Tuberculosis

Chemical dependency

Migraine headaches

Please list any other pertinent health information:

Do you smoke?

Do you drink alcohol?

Do you take any medications, including eye drops?

List any medications you take, including eye drops:

Do you have any medical allergies?

List any medical allergies - medications, latex, etc:

Please take a moment to review our Optomap Retinal Screening Policy.

Optomap Retinal Screening Policy - effective October 1, 2020.

Late Cancellation and Missed Appointment Policy

Appointments are in high demand as we are now booked out several weeks. We have unfortunately experienced a significant increase in missed appointments and last minute cancellations. It is unfair that everyone else now has to wait longer for their appointment. Optix Optometry has decided to institute a policy for late cancellations or missed appointments. If 24 hours advance notice is not given, there will be a $50 fee for each missed appointment. Missed appointments will not be rescheduled until any fees are paid.

I authorize Drs. Steve and Stacey Beck to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such eye care to third party payers for the purpose of payment, and/or health practitioners until otherwise requested in writing. I assign all insurance benefits, if any, to Drs. Beck otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Optix Optometry requires payment in full for examination fees and all materials at the time of service or ordering. We accept cash, checks, money orders, Visa, Master Card and Discover. An overdraft fee of $25.00 will be assessed for returned checks. Client(s) will be responsible for any balances owed. If balances are not paid, the client will be responsible for all collection agency fees and attorney fees totaling an additional 25% of the current account balance at the time the account is sent to collections.

All patients who wear or elect to wear contact lenses will be enrolled in the Contact Lens Care Program and will be assessed any applicable professional fees related to contact lens fitting and evaluations.

“I have read the Optix Optometry HIPAA Notice of Privacy Policy posted either on the web site or in the office waiting area.”

“I have read the contents of this page and understand by signing my name, I agree to all of the terms and conditions.”

By checking the next box, you agree to the terms of Authorization, Financial Policy and HIPAA Statement.

Enter your full first/last name to electronically sign this form - use guardian's full first/last name if completing for a minor:

Date:

Welcome!

Patient Information

Financial and Insurance Information

Eye Health History

Health History

Medications

Authorization, Financial Policy and HIPAA Statement