Established Form

Welcome back! Let us know if we need to make any updates. Thank you!
Patient Name*
If applicable, guardian completing form: Name and relation
ELECTRONIC/DIGITAL CONSENT. As a reminder, we continue to provide copies of prescriptions and invoices via our patient portal to reduce paper waste. Portal Access Confirmation:

Continue patient portal access.I prefer paper documents.
Confirm Email
example@example.com
Is there any information that needs to be updated?*

Update AddressUpdate EmailUpdate Phone NumberUpdate Medical Insurance/Vision PlanNo changes since last visit.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Policy Holder Relation:
    ; if not self, Name       Date of Birth

Medical Insurance:
i.e. BCBS, Aetna, Cigna, Medicare, etc.
Member ID#

Vision Plan:
i.e. VSP, Eyemed, Spectera, Superior Vision, etc.
Policy# or Last 4 SSN
Type in new information and/or take photo of new insurance card(s)

FINANCIAL DISCLAIMER. By signing below, you authorize your plan carrier to directly pay EaDo Optics. You also authorize EaDo Optics to release any information required for payment to be made. If your plan carrier does not pay, or partially pays, you understand that you are responsible for payment in full or the remaining balances.
Signature of Patient or Authorized Representative:*

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Notice of Privacy Practices. Please find it at https://eadooptics.com/privacy-practices/

The signature below indicates that I have been provided with a copy of the Notice of Privacy Practices for the authorized party listed above and have read and understood its content.
Signature of Patient or Authorized Representative:*

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Date

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