• Ridgefield Vision Center - Patient Forms

    Welcome to Our Practice! This information will allow us to begin the process that ensures your eye health and vision remain at their best, and that your health and lifestyle needs are met. Thank you for your help.
  • Title

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status

  •  -
  • When was your last physical exam?

  • When was your last eye exam?

  • Are you older than 18 years?*
  •  -
  • Do you have MEDICAL insurance?*
  • Date of birth of parent/spouse*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have VISION insurance?*
  • Date of birth of parent/spouse*
     - -
    2 digit month, 2 digit day, 4 digit year

  • "I request that payment of benefits be made to me or the doctor for any services provided. I also authorize any holder of medical information about me to release to the carrier and its agents any information needed to determine these benefits or the benefits payable for related services."

    "I understand that any services not covered by insurance and co-pays are due at time of service."

    "I also acknowledge that I will have an opportunity to receive a copy of the Privacy Practices and Policies of this practice."

  • Personal & Family Medical History

    Please note any personal and/or family medical history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

  • Blindness*
  • Please check all that apply*
  • Cataract*
  • Please check all that apply*
  • Crossed Eyes*
  • Please check all that apply*
  • Glaucoma*
  • Please check all that apply*
  • Macular Degeneration*
  • Please check all that apply*
  • Retinal Detachment/Disease*
  • Please check all that apply*
  • Arthritis*
  • Please check all that apply*
  • Cancer*
  • Please check all that apply*
  • Diabetes*
  • Please check all that apply*
  • Heart Disease*
  • Please check all that apply*
  • High Blood Pressure*
  • Please check all that apply*
  • Kidney Disease*
  • Please check all that apply*
  • Lupus*
  • Please check all that apply*
  • Thyroid Disease*
  • Please check all that apply*
  • Please check all that apply*

  • Social History

    This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

  • Do you use tobacco products?
  • Do you drink alcohol?
  • Do you use illegal drugs?
  • Have you ever been exposed to or infected with:

  • Your Medical History

  • Do you have any allergies to medications?*
  • Do you currently take any medications (including oral contraceptives, aspirin, over the counter medications and home remedies)?*
  • Have you had any major injuries, surgeries and/or hospitalizations? Please include LASIK and Cataract Surgery*
  • Check any of the following if you have had:
  • Eye infections or eye injury?
  • Are you pregnant and/or nursing?
  • Do you wear glasses?*
  • Do you wear contact lenses?
  • Type of contact lenses:

  • Are they comfortable?

  • Have you experienced?

  • Loss of Vision*
  • Blurred Vision*
  • Distorted Vision / Halos*
  • Loss of Side Vision*
  • Double Vision*
  • Eye Dryness*
  • Mucous Discharge (eyes)*
  • Eye Redness*
  • Sandy or Gritty Feeling (eyes)*
  • Eye Itching*
  • Eye Burning*
  • Foreign Body Sensation (eyes)*
  • Excess Tearing / Watering*
  • Glare / Light Sensitivity*
  • Eye Pain or Soreness*
  • Chronic Infection of Eye or Lid*
  • Styes or Chalazion*
  • Flashes / Floaters in Vision*
  • Tired Eyes*
  • Frequent Headaches*
  • Seasonal Allergies*
  • Neck Strain*
  • Sleeplessness*

  • POLICY FOR MEDICAL VISITS

    Medical visits include examination and treatment for infections, injuries, allergies, headache, eye pain, diabetic eye care and eye disturbances other than comprehensive eye health and vision exams, eyeglasses, and contact lenses.

    Medical visits and medical insurance coverage are separate from optical coverage. Medical visits are covered by outpatient medical insurance, the same as visits to a family doctor. These visits are not optical, and should be covered regardless of whether the insurance includes optical coverage, which may allow an eye exam every one or two years. 

    For example: 
    If you see the doctor for a medical visit, our staff will gladly file a claim with your insurance carrier. if we are considered out-of-network with your plan, payment will be required at the time of service and documenation can be provided for reimbursement.

    THE CHARGES ARE ULTIMATELY YOUR RESPONSIBILITY. Please help us get your benefits by providing current and accurate insurance information.

    I have read and agree to the terms stated above.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • HIPAA Authorization of Release of Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • I authorize the release of information including the diagnosis, records, examination rendered to me and financial information. This information may be released to:

  • This Release of Information will remain in effect until terminated by me in writing.

  • Messages

  • I would like to be contacted via*
  • If unable to reach me:
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Ridgefield Vision Center
    Contact Lens Evaluation Agreement


    The charge for evaluating and determining your suitability for contact lens wear is not included in the comprehensive exam fee or refraction fee. A comprehensive eye exam must be performed prior to the contact lens evaluation. Your insurance plan may or may not cover the cost of the contact lens evaluation. The evaluation fee is for professional services and does not include the cost of the contact lenses.


    The following products and services are included in the contact lens fitting and evaluation fee:

    • Professional examination of contact lens fit and power
    • Contact lens related follow-up care for 90 days
    • Trial pair of contact lenses (if available)
    • New contact lens care and trial size solution, or valuable coupon to purchase solution
    • Manufacturer rebates to purchase contact lenses through Ridgefield Vision (if available)

    The evaluation fees are as follows:

    Annual Contact Evaluation Fee Lens Types
    Level 1: Basic $105  Soft spheres (excluding monovision) 
    Level 2: Advanced $135  Soft torics (astigmatism) Soft monovision
    Soft multifocals 
    Level 3: Complex $190  Rigid spheres
    Rigid multifocals
    XR torics (advanced astigmatism)
     Level 4: Medically Necessary  $600 and up
    Evaluation and fee to be determined by the doctor at the time of visit     		 Keratoconus/Post-Surgical 

    Training:


    If you are new to wearing contact lenses or need a review of how to properly insert and remove them, we will provide one-on-one training. This is to make sure you are comfortable handling, inserting, removing, cleaning and disinfecting your lenses. These fees are in addition to your contact lens evaluation costs and are not billable to your insurance.

    Training Fee Services covered
    Training Level 1 $30 Re-training and review
    Training Level 2 $50 Full training for a first time wearer

    Your contact lens prescription will be given after the initial evaluation period is successfully completed (examination and follow-up visits) and after all fees are paid. Fees for professional services, such as examination fees and contact lens evaluation fees, are not refundable.

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