Patient Forms

Full Name*
Date of Birth*

MonthDayYear
Date
Martial Status
Email Address
example@example.com
Home Phone
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone*
Please enter a valid phone number.
Employer
Occupation
Guarantor (person who carries insurance)*
Guarantor Date of Birth

MonthDayYear
Date
Guarantor Address:
Guarantor's Employer:
Primary Medical Insurance:
Secondary Medical Insurance:
Primary Vision Insurance:
Secondary Vision Insurance:
Guarantor's Social Security # *(Minimum entry last 4 of Social)*
Former Optometrist:
Last Eye Exam:
Primary Medical Physician:
Physician's Phone:
Please enter a valid phone number.
Physician's Address:
Emergency Contact:
Phone:
Please enter a valid phone number.
Relationship to Patient:
Who may we thank for referring you to us?
Please Sign and Date Below.

Signature Date*

You may save or print a copy of our Privacy Notice, for your records. Click NEXT to sign the Consent to Privacy and acknowledge receipt of this notice.

Consent for Release and Use of Confidential Information
I, Guardian/Patient* , hereby give my consent to Dr. Sanders-Maubach,
to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of:   Name of Patient*     Date of Birth*

I acknowledge receipt of the Optometrist Notice of Privacy Practices . The Notice of Privacy Practices provides detailed in formation about how the practice may use and disclose my confidential information .

I understand that the Optometrist has reserved the right to change the privacy practices that are described in the Notice. I, also, understand that a copy of any revised Notice will be provided to me upon request.

I understand the consent is valid until it is revoked by me. A written revocation of consent must be sent to the Optometrist's office, at the address listed above. I also understand that I will not be able to revoke this consent in cases where the Optometrist had already relied on it to use or disclose my health information.

   Guardian/Patient Signature*  Relationship to Patient*  Date*

Please list the name(s) of any person(s) that you authorize Dr. Sanders-Maubach to discuss your personal health information (PHI) with:   Authorized Person(s)

Please list the name(s) of any person(s) that you authorized to pick up any hardware/products on your behalf: (this does not include your PHI)    Authorized Person(s)

Please check the box next to your choice.*

Yes, I want to have retinal photos taken of my eye for documentation.No, I do not wish to have retinal photos taken.
Signature: Signature Date: Date

Optical Coherence Tomography (OCT) is a non-invasive scan that uses light waves to take cross-section images of your retina. This screening does not require dilation and allows your doctor to see all nine distinctive layers of your retina.

Vision threatening diseases such as glaucoma, macular degeneration and diabetic retinopathy often have no outward signs or symptoms in the early stages. This unique technology can help our doctor detect vision threatening and systemic diseases in their very early stages, when they are most treatable.

The screening fee is $30, due when services are rendered. This procedure may be billed to your medical insurance, if medical diagnosis is determined by the doctor. If filed medically, it is no longer a screening and considered Ophthalmic Diagnostic Imaging (Nerve/Retina), in which the amount billed will differ from the screening charge. You may be required to submit a receipt for reimbursement from your insurance provider.

Yes Signature: Signature Date: Date

No Signature: Signature Date: Date
Should be Empty: