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  • Patient Registration

    Please complete the form in its entirety to help us better serve you.


  • In case of emergency...
  • Reason For Visit

    As we prepare to transition into medical billing, it’s important for us to understand the nature of your visit to help determine which insurance benefit—vision or medical—may be most appropriate. Please describe your primary reason for today’s appointment.
  • 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.

  • Medical History

    Please fill in the form below
  • Please indicate if you have been diagnosed with any of the following medical conditions.
  • Medications

  • Allergies

  • Past Ocular History

  • Social History

  • Family Medical History

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  • General Consents

    Please read the policies carefully and fill out the form in its entirety so we can better serve you.
  • Internal Ocular Health Evaluation

    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 advised that these services are completed the same day of the yearly exam to avoid extra charges especially since some insurances only cover one routine eye exam visit per year. Be sure to plan your visit accordingly. 

  • Vision Insurance Information

    (not the same as Medical Insurance)

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  • Contact Lens Prescription (Renewal) Policy

    The policy disclosure outlines essential information for obtaining and renewing contact lens prescriptions. It ensures that all current, new, and future contact lens wearers are informed about evaluation procedures, follow-up responsibilities, and associated charges.
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    To purchase contact lens materials, it is required by law to have an active contact lens prescription.  This applies to all patients - even if you have worn contact lenses in the past and/or even if the prescription does not change. The state of Georgia requires that a contact lens evaluation be performed every 12 months to renew contact lens prescriptions.
    To comply with contact lens wearer laws your contact lens prescription will be issued right after the contact lens evaluation is completed. You will also be able to access you prescription parameters and order lenses through the MARLO/OPAL patient ordering portal. 

    If trial lenses need to be ordered, we strongly recommend postponing any contact lens supply order until fully satiSfied with issued lenses.  If you are not fully satisfied with dispensed or ordered trial lenses, it is imperative that you schedule a contact lens follow-up as soon as possible.  Contact lens follow-ups must be perform within 45 days of initial exam to avoid extra charges and it is the patients responsibility to schedule them if needed.  If a patient requires multiple contact lens prescriptions, fittings or evaluations, additional charges will apply.
    Payment for contact lens evaluations to renew contact lens prescriptions, as well as with 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 

    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-refunded 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. 

    REGARDLESS OF PAYMENT TYPE USED, AN OFFICE CHECK WILL BE ISSUED ONCE THE CREDIT HAS BEEN GRANTED FROM DISTRIBUTOR AND MUST BE PICKED UP AT THE OFFICE IN PERSON. If a check needs to be cancelled/stopped there will be a $40 fee per occurance. 

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