Eye Appointment Form

Patient Intake Form

Welcome to our family owned practice! Thank you for choosing us for your eye care needs. We are delighted to have you as our patient and appreciate the confidence you place in us. Please take a moment to complete the following information. If you have any questions, please do not hesitate to ask.
Full Name*

First NameMiddle NameLast Name
Preferred Name / Nickname
Nickname
Phone Number*
Please enter a valid phone number.
Email*
What is your Gender?*

MaleFemaleOther or Prefer Not to Answer
Patient Date of Birth*

MonthDayYear
Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(If patient is under 18 years old) Name of Parent/Guardian
Parent/Guardian relationship to the patient?
When was your last eye exam?*

A year ago2-3 year ago3-5 years agoMore than 5 years agoOther
Do you currently wear any of the following*

GlassesContact Lenses - SoftContact Lenses - HardBoth Glasses & ContactsNone
Do you have a Vision and/or Medical Insurance?*

YesNo

Insurance Information

	Insurance/Plan Name	Group Number	Policy Number (ID)
Vision Insurance
Medical Insurance 1
Medical Insurance 2
Other Insurance

Provide Policy Holder Info Below, if its not you:

	Last Name	First Name	Date of Birth	Last 4 of SSN
Policy Holder Info

Take photo of insurance card(s) include front of card)
Take photo of insurance card(s) include back of card)
OR, Upload photo(s) of insurance card (include back as well)

Cancelof

Vision VS. Medical Insurance Plans

Vision benefit plans such as VSP are not medical insurance. They pay for an annual eye wellness exam and a prescription for glasses and/or contact lenses. They usually provide patients with a hardware benefit and allowances. They DO NOT cover any medical eye problems. If you have diabetes, you will be asked to return for a second medical office visit for a thorough retinal evaluation. Medical insurance covers anything that happens to your body including your eyes: diabetic eye exam, eye allergies, dry eye evaluation, scratched cornea, eye infections, management of chronic eye diseases such as macular degeneration, cataracts and glaucoma.
We do require a card on file for new patients with medical/emergency appointment. We will only charge if you have ignored our three statements and have not responded to our phone call. Please Acknowledge with your Initials.
Patient Initials:*
HIPPA & Privacy Policy

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out the following:Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment).Obtaining payment from third party payers (my insurance company).The day to day healthcare operations of your practice. I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you agree, you are often bound to comply with the restrictions.I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your records to others unless you direct us to do so or unless the law authorizes or requires that we do so. You may see your record or get more information about it by contacting our privacy officer.
I allow the following individual(s) to obtain information on my behalf.
Patient Name*

Consent for Dilation

In our office, patients reserve the right to refuse any test or diagnostic procedure, despite our recommendations. I understand the risks of refusing these procedures and that without them the health of the eyes cannot be completely evaluated.
Patient Choice*

Yes - I consent to dilation today if recommended by my doctor.No - I decline dilation today and assume all risks and complications that arise and will not hold Bonney Lake Family Eye Care and Northwest Family Eye Care responsible for any consequences secondary to my decision.
Contact Lens Fitting Fee

Contact lenses are a medical device regulated by the Food and Drug Administration and require a valid prescription by an optometric physician. Evaluating your eyes for contact lens use is considered an additional service that is typically not part of your routine eye and not fully covered by most vision plans. Therefore, there may be an additional fee if you choose to be evaluated for contact lenses. This fee starts at $80.00 and increases based on the contact lens type. Contact lens evaluation fee ranges between $80 -130. Contact Lens Evaluation fees vary for rigid gas permeable, hybrid or custom contact lenses.
Patient Choice*

Yes - I accept the responsibility of the contact lens evaluation fee.No - I decline the contact lens evaluation acknowledging that I will not be given a prescription for contact lenses today.
Missed or Cancelled Appointment Policy

Any appointment that is missed or cancelled within 24 hours of the appointment will be subject to a charge of $50.00. Please help us avoid charging this fee! If you're no longer sure if you can make it to these appointments, please call our office as soon as possible.
Patient Initials:*

Financial Responsibility

I understand that my portion is to be paid at the time services are rendered. The undersigned will be responsible for any bills incurred in this office regardless of insurance. Accounts over 90 days old are subject to a 2% interest charge and will be sent to the collection agency. In this case, you are responsible for full payment of your account and any collections feeds incurred. There will be a service charge of $40 on all returned checks. I understand that screening tests may not be covered by my insurance and that I will be responsible to pay in full for these tests. Professional services are not refundable and all product sales are final. Any returns that are approved may be subject to a restocking fee. I authorize payment from my insurance to be paid directly to Bonney Lake Family Eye Care and Northwest Family Eye Care. I understand that billing any out of network insurance will be my responsibility. I understand that all benefits quoted to be are not a guarantee of payment by my insurance company and that final determination can be made when the claim is processed. I authorize the use of this form on all insurance submissions and the release of all information to my insurance companies. I authorize my doctor to act as my agent in helping me obtain payment from my insurance companies. I permit a copy of this authorization to be used in place of the original.
Patient Initials:*

I,*

First NameLast Name
give my express permission to Dr. Gurpinderjeet Kaur, to obtain and access to all of my medical records for both her Offices (Bonney Lake Family Eye Care and Northwest Family Eye Care). I understand that my personal and medical information may be stored on a password-protected secure cloud service.
Patient Name*
Today's Date*

MonthDayYear
Date
Should be Empty:

	Self	Mother	Father	Brother	Sister	Daugher	Son
Diabetes
Hypertension
Cancer
Thyroid
Macular Degenration
Glaucoma

	0	1	2	3
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

	0	1	2	3	4
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Patient Intake Form

Vision VS. Medical Insurance Plans

HIPPA & Privacy Policy

Consent for Dilation

Contact Lens Fitting Fee

Missed or Cancelled Appointment Policy

Financial Responsibility