Patient Enrollment Form

Welcome to Peachtree Eye Associates

We’re excited to care for your vision.
To prepare for your visit, this form helps us:

• Verify vision insurance or confirm self-pay
• Confirm your appointment
• Schedule the correct type of visit for your needs
• Update any changes to your insurance, contact information, or medical history

⏱️ This form takes about 5–7 minutes to complete.

Please complete this form even if you have visited us before.
Completing it allows us to review any updates, avoid delays and acknowledge current office policies so your visit runs smoothly.

Demographics
Name*

First NameLast Name
Date of Birth*
MM/DD/YYYY
Sex*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:*
E-mail*
example@example.com
In case of emergency...
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Vision Insurance Information & Self Pay

Vision plans are different from medical insurance
Peachtree Eye Associates is an independent optometric practice located inside LensCrafters.
While we share the same location, we operate separately and manage our own scheduling, billing, and insurance participation.

Important to know before continuing:
- Vision insurance plans are separate from medical insurance.
- Not all medical plans include vision coverage.
- The vision plans we participate with may differ from those advertised by LensCrafters.
We participate only with the vision plans listed below. If your plan is not listed or cannot be verified prior to your visit, services will be provided on a self-pay basis.

If you are unsure which vision plan you have, please contact our office before your appointment so we can assist you.
Our office will make every effort to verify your benefits but it is your responsibility to present the adequate insurance or vision discount prior to check-in.*

I understand that if insurance information or any other discount plan is not presented or verified at the time of registration, it will be my responsibility (or the responsibility of the guardian if the patient is under 18 years of age) to personally submit a claim to my insurance carrier if possible. As a result, no additional discounts will be applied after services have been rendered and payment has been received.Additionally, it is important to note that most vision plans only cover one exam per year, and our service fees are non-refundable. If there are any concerns regarding issued prescriptions, they must be addressed within 45 days of the exam date. After this period, a $45 fee will apply for any prescription re-evaluation.
Please select vision plan*

EyemedSpecteraVision Benefits of America (VBA)AvesisSelf Pay (No Vision Insurance)
Primary Member*

First NameLast Name
Primary Member's DOB*
MM/DD/YYYY
Last 4 Digits of SS #*
Last 4 Digits of Primary Member's Social Security Number

Self-Pay Acknowledgment

My visit will proceed without vision insurance.
I understand and agree to proceed as a self-pay patient under these terms*

If I choose not to proceed with my visit after arrival due to insurance eligibility or cost concerns, the appointment will be treated as a same-day cancellation. Resulting in a $40 same-day cancellation fee. I may contact the office prior to my visit if I would like assistance understanding expected fees.

Reason For Visit

To help us prepare for your visit and determine the most appropriate type of appointment, please tell us the main reason you are coming in today. Some visits are considered routine vision exams, while others are medical eye visits. Your response helps us schedule appropriately and review benefits in advance.
Visit Type Descriptions
Routine Eye Exam (Glasses Prescription)
Annual eye exam to check vision and eye health and receive a glasses/spectacle prescription.

Contact Lens Exam (Glasses + Contact Lens Prescriptions)
Includes a routine eye exam plus contact lens evaluation. Required to receive or renew a contact lens prescription.

Medical Eye Visit (Eye Problem or Concern)
Visit for a specific eye issue such as redness, pain, infection, dry eye symptoms, sudden vision changes, or injury.

For contact lens wearers:
If you wear contact lenses but are not scheduling a contact lens exam today, please note that you will not receive a contact lens prescription and will not be able to order contact lenses until a contact lens evaluation is completed.

Even if you are not scheduling a contact lens exam today, we ask all patients to review our contact lens policies for future reference.
Please select the option that best describes your visit*
What is the primary reason for this visit?*
Appointment Policy
We kindly ask that any cancellations be made at least 24 hours in advance. A $40 fee will apply for no-shows or cancellations made with less than 24 hours’ notice.

Please note: We offer a 10-minute grace period for late arrivals. Patients arriving more than 10 minutes late may need to reschedule to avoid impacting other patients' care.

Thank you for helping us stay on time and provide the best experience for everyone.

Allergies
Are you allergic to any of the following?*

No known drug allergiesFood: NutNo known other allergiesBee stingsNo latex sensitivityEnvironmental/SeasonalLatex sensitivityOther, please specify

Social History
Do you drink alcohol?*

YesNo
Tobacco use ?*

Heavy Tobacco SmokerLight Tobacco SmokerFormer SmokerNever smoked

Internal Ocular Health Evaluation

Recommended testing to evaluate the internal health of your eyes
Since many eye problems can develop without symptoms, an internal ocular evaluation is an important component of a routine eye exam. To accomplish a full internal health assessment, our doctors highly recommend that all patients have a retinal scan (Optomap) and pupil dilation.

The Optomap captures a digital image of about 80% of the inside of the eye without side effects but most insurances do not cover it.

Pupil dilation is achieved by applying a series of drops and can take 15-20 minutes to take effect and about 4-6 hours to wear-off.

It is often recommended that these services be completed on the same day as your annual exam to avoid the need for additional visits, especially since some vision plans cover only one routine eye exam per year. Please plan your visit accordingly.
Optomap - I give consent to have the retinal image. An additional fee of $39 will apply.*

YesNo
Pupil Dilation - I give consent to be dilated. I understand there are side effects such as blurry vision and light sensitivity.*

YesNo

General Consents & Office Policies

Please review and acknowledge the following policies. These consents help us provide safe, timely care and ensure transparency regarding services.
Medical visits such as red eye, pink eye, corneal problems due to contact lens overwear or foreign bodies will be charged as out-of-pocket expenses to the patient. We will provide you with a detailed receipt if you choose to file with your medical insurance provider.*

I understand Peachtree Eye Associates chooses not to participate in medical insurance billing. So, if the routine eye exam can not be performed today due to a medical ocular problem the visit will start at $80 plus any other additional tests that might be needed.
Acknowledgement of Glasses Prescription Release*

By checking this box, I acknowledge that I will receive a copy of my eyeglass prescription immediately after the refractive eye examination. I understand that not all visits will result in a glasses prescription, but the doctor will discuss it if applicable.
Acknowledgment Refund & Credit Issuance Policy

Refunds or credits apply only to eligible materials and must fall within the manufacturer’s or distributor’s allowable return timeframe. Professional services, including eye examinations, evaluations, and testing, are non-refundable once rendered. Regardless of the payment method used, any approved material credit or refund will be issued by office check once the credit has been received from the distributor or vendor.Refund checks must be picked up in person at the office.If a refund check must be cancelled or a stop-payment request is required, a $40 processing fee per occurrence will apply.
Acknowledgement of Recall Practices*

I authorize to be pre-appointed for my annual routine eye exam and will be reminded about visits via LensCrafter's recall system. A copy of The Policy of notice of Recall Practices for Peachtree Eye Associates can be provided upon request. Reminder calls may be prerecorded or live, and text message data rates may apply.
Acknowledgement of Receipt of Notice of Privacy Practices*

I understand The Privacy Act was established by the government to protect all my medical information. The law requires Peachtree Eye Associates, P.C. to inform me that my medical information is confidential and can only be released upon my signed request.
Acknowledgment of Records Release Policy*

Medical records will be provided only after a written request is submitted and will not be process on a walk-in bases and per HIPAA statues, our practice is granted 30 days from the time of the request to process the records. The patient or party requesting records will be responsible for the costs associated with producing, printing and mailing if needed. Records Request form will be provided upon request.
By signing below, I acknowledge receipt, review, and understanding of all office policies, consents, and notices presented in this form and agree to move forward with examination.
Signature*

Clear

Contact Lens Prescription (Renewal) Policy

This policy explains the requirements for obtaining or renewing a contact lens prescription. It applies to all patients, including current, new, and future contact lens wearers, and outlines evaluation requirements, follow-up responsibilities, and associated fees.
To purchase contact lenses, an active contact lens prescription is required by law. This applies to all patients—even if you have worn contact lenses previously and even if your prescription does not change.
The state of Georgia requires a contact lens evaluation every 12 months to renew a contact lens prescription.

In compliance with contact lens wearer laws, your contact lens prescription will be issued after the contact lens evaluation is completed. You will also be able to access your prescription parameters and order lenses through the patient ordering portal either MARLO or OPAL.

If trial lenses are required, we strongly recommend postponing any contact lens supply order until you are fully satisfied with the prescribed lenses. If you are not fully satisfied with dispensed or ordered trial lenses, it is important to schedule a contact lens follow-up as soon as possible.

Contact lens follow-up visits must be completed within 45 days of the initial exam to avoid additional charges. It is the patient’s responsibility to schedule follow-up visits if needed. If multiple contact lens prescriptions, fittings, or evaluations are required, additional fees will apply.

Payment for contact lens evaluations to renew contact lens prescriptions, as well as all other professional fees, is a non-refundable service.

CONTACT LENS EVALUATION FEES are based on the complexity of evaluation.

I UNDERSTAND THAT THESE FEES ARE AN ESTIMATE AT CHECK-IN AND ARE SUBJECT TO CHANGES BASED ON THE DOCTOR’S FINAL ASSESSMENT. CONTACT LENS EVALUATIONS ARE PRICED ACCORDING TO LENS TYPE, MODALITY, USE AND COMPLEXITY OF FITTING.

Soft Standard Fitting	$70
Soft Extended Wear Fitting	$90
Soft Color Fitting	$90
Soft Astigmatism Fitting	$90
Soft Monovision Fitting	$100
Soft Multifocal Fitting	$100
Hybrid Standard Fitting	$155
Hybrid Multifocal Fitting	$190
Hybrid Keratoconus/PS Fitting	$275
Gas Permeable Standard Fitting	$175
Gas Permeable Premium Fitting	$225
Scleral Fitting Standard/Premium	$375/$400

I ACKNOWLEDGE THAT I UNDERSTAND THE POLICES REGARDING THE CONTACT LENS EVALUATION AND AGREE TO THE ASSOCIATED FEES. For Patients age 45 and older, or those wearing multifocal or myopia control lenses, will be automatically categorized under the Monovision/Multifocal Evaluation tier at check-in.

All contact lens evaluation fee are non-refundable and only includes up to two follow-up visits within a 45 day period from the initial exam. We will schedule your follow-up appointment when it is most convenient to you. However, it is the patient’s responsibility to make sure the follow-up visits are completed within the 45 day period. If one fails to keep or schedule follow-up visits during the 45 day period, additional fees will apply.

ADDITIONAL FEES

Additional 20 minute training session	$39
3rd visits or if it's after the 45 day period	$39
For visits 3 months after initial exam	$84
For visits after 6 months from initial exam	Full Exam Cost

Materials Return Policy

If you purchased contact lenses from our office and are dissatisfied for any reason with the purchase materials, the following polices will apply.

Certain, soft contact lens boxes can be returned for credit or refunded within 60 days of purchase. As long as the boxes are unopened, undamaged, and unmarked.

Furthermore, if boxes are returned and a courtesy diagnostic lenses were supplied at the time of purchase, a dispensing fee will apply.

Certain toric (ex: XR lenses), color (BioColors, Eyedia) and custom lenses are non-refundable once the order has been placed.

Gas Permeable, scleral, hybrid, and some soft contacts are made to order and can also be returned within 60 days, but a $35 re-stocking fee per lens is required depending on lens type, manufacturer and design.

If lenses were shipped to home and do not arrive in the expected time; we need to be notified immediately. Shipping charges are non-refundable and never guaranteed. As with any return, exchange or claim needs to be submitted to distributor and manufacturer within 60 days of order for investigation.

Lastly, if any contact lens product is not picked up within 6 months of inital order and we are not able to establish communication; the lenses will be destroyed as no refund would be issued as they would have exceeded the 60 days period for any returns from manufacturer or distributor.

Contact Lens Evaluation Consent (Optional)*

Proceed with Contact Lens Evaluation: I have reviewed and understand the Contact Lens Policies and wish to proceed with a contact lens evaluation today.Decline Contact Lens Evaluation. I have reviewed and understand the Contact Lens Policies and choose NOT to proceed with a contact lens evaluation today. I understand that no contact lens prescription will be issued, and contact lenses cannot be ordered without a completed evaluation.
Acknowledgement of The Fairness to Contact Lens Consumers Act.*

By checking this box, I acknowledge that I will receive my contact lens prescription at the end of the eye exam. Although released in compliance with the FTC Contact Lens Rule, I understand that I should not order contact lenses until I have confirmed comfort, clarity, and consistent wear. If I am not fully satisfied with my lenses, I may schedule a contact lens follow-up visit at no charge within 45 days of my initial exam. Additional fees will apply beyond this window. I will also receive a link from MARLO or OPAL, our trusted soft contact lens ordering platform, for a seamless ordering experience—should I choose to purchase through this office and support this small business.
Signature*

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Welcome to Peachtree Eye Associates

Demographics

Vision Insurance Information & Self Pay

Self-Pay Acknowledgment

Reason For Visit

Medical History

Medications

Allergies

Past Ocular History

Social History

Family Medical History

Internal Ocular Health Evaluation

General Consents & Office Policies

Contact Lens Prescription (Renewal) Policy