Returning Patient Form

Returning Patient

If we have seen you in the last 3 years (2019 or later) please continue to fill out these forms. **If it's been longer than 3 years (2018 or earlier) please got to "New Patient Forms" to fill those out instead.**
The information you enter on this page is submitted to a secure site and will be kept completely confidential.
Patient Name *

Prefix First Name Middle Name Last Name Suffix
Nickname (Name Patient Uses)
Preferred Name
Your Name
If Not the Patient
Relationship To Patient
Home Phone *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Email *

Confirmation Email Confirm email
Preferred Primary Method of Contact *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Last Four of Social Security No.
Date of Birth *

Month Day Year
Date
Sex *
Gender
Employer (if any)
What is the main reason for your visit?

Vision Insurance Information

*This information will help us verify coverage for your annual eye exam, eyewear, or contact lenses*
I dont have Vision Insurance
Name of Insurance Company
Policy or Subscriber ID
Please include any Alpha Prefix
Group Number
Policy Holder Name
Policy Holder Date of Birth

Month Day Year
Policy Holder Relation to Patient
Policy Holder Last Four of Social Security No.
Medical Insurance Information

*This information may be needed in the event there is a medical finding during your exam, such as diabetes, glaucoma, macular degeneration, eye infection, etc*
I dont have Medical Insurance Same Information as Above
Name of Insurance Company
Policy or Subscriber ID
Please include any Alpha Prefix
Group Number
Policy Holder Name
Policy Holder Date of Birth

Month Day Year
Policy Holder Relation to Patient
Upload Insurance Card Image

Browse Files
Please upload an image of the front and back of your insurance card Cancel of

Optomap Digital Imaging

Optomap is a non-dilated technology that uses a safe scanning laser to
create an image of the inside of the eye. This technology allows us to
document the internal structures of the eye and detect over 100 different
eye diseases such as retinal detachments, diabetic retinopathy, glaucoma,
macular degeneration, and retinal changes due to high blood pressure and
cholesterol.

Dr. Cole and Dr. Dodd strongly recommend images be taken each year on
all patients, no matter the age, to monitor for any changes. Once the
image is taken, it will be reviewed with you by the doctor in the examination
room.

Click here http://optomap.com/en-US/ for more in-depth information about Optomap.

The procedure is quick and simple! It is not covered by most insurance
companies, as they do not cover screenings. We offer the digital imaging
for $35 on the day of your examination.

Optomap Consent

	Please Check Selection
Yes - I would like to have Optos performed
Not yet - I have more questions
Not at this time

Consent For Dilation *If recommended by doctor*

Many Diseases such as diabetes, hypertension, glaucoma and tumors of the eye, as well as tears and holes in the retina, can be detected with dilation. Dilation requires placing drops in the eyes to enlarge the pupil which allows a thorough examination of the inside of the eye for these and other problems. The side effects can be blurred vision and light sensitivity for about 2-4 hours. There is no additional charge for this procedure.

Dilation

	Please Initial Selection	Relationship (if not patient)
Yes - I consent to having dilation performed today
No - I have more questions
Not at this time

HIPAA Privacy Consent

To Our Patients:

Federal law requires that we provide you with a copy of our Privacy Notice.

The Privacy Notice explains how we may use and disclose health information about you. We ask that you sign this form for our records so that we may document your receipt of the Notice.

If you have questions about the Privacy Notice, please feel free to direct these to our Privacy Officer at any time. The name and contact number of the Privacy Officer is listed on your copy of the Privacy Notice.

This HIPAA Notice was provided to:

	Type Name	Date Signed
Patient (self)
Parent/Guardian to minor
Guardian/POA to adult dependent
Other

Signature for HIPAA

*No signature will communicate Decline for Consent Clear
Consent to Disclose Information

We understand that there may come a time where a family member, friend, or other, will need to speak with us on your behalf. This may include, but is not limited to, appointment details, financial information, personal health information, etc. Please list the information of any person that may contact us on your behalf, as consent for us to speak with them. You may also notate Declined Access for certain individuals.

*A blank form will indicate that you have chosen to Decline Consent for Release of Information.

Consent for Individuals *if more than 5, please contact our office directly, after submission

Payment Information

Professional fees are due upon completion of services. Although we do bill most insurances, please be advised that payment is still your responsibility. For your convenience, we accept Visa, Mastercard, Discover, personal check and cash. Please note that all returned checks are subject to a $40 charge.
I acknowledge the Payment Information Disclaimer *
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