Registration Form

Eyecare Center of DuPage, Ltd. - INSURANCE AUTHORIZATION
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I authorize the staff & doctors of the Eyecare Center of DuPage, Ltd. to bill by insurance company/Medicare as my agent on my behalf.I assign payment of my insurance/Medicare benefits directly to the Eyecare Center of DuPage, Ltd. on my behalf.I understand I am personally financially responsible to the Eyecare Center of DuPage, Ltd. for payment of this account regardless of any insurance coverage I may have. The filing of any claims to my insurance does not remove me from my financial responsibility.
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Eyecare Center of DuPage, Ltd. - CONTRACT FOR CARE
APPOINTMENTS Any changes made to time reserved for you affects many other people. A minimum of 24 hours advance notice of appointment changes is required to avoid a $65 Appointment Late Change Fee.

MINOR PATIENTS Minor patients must be accompanied by an adult or guardian.

FINANCIAL POLICIES Payment is required at the time services are rendered. A minimum 1/3 non-refundable deposit is required prior to ordering materials, with payment-in-full prior to dispense. Since eyeglasses and contact lenses are custom fabricated for you, orders once placed cannot be canceled and items cannot be returned for refund.

CONTACT LENSES Contact lenses are regulated devices and require a doctor's prescription. Yearly health examination + contact lens evaluation is required to maintain a valid prescription. No order fulfillment or authorization will be made available if prescriptions are allowed to lapse. Contact lens prescriptions will be provided when the doctor deems the fit to be complete and payment has been received for all account balances.

HIPAA PRIVACY POLICIES A printed copy of our privacy policies is on display and available in our office. You may download a copy here: Privacy Policies
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By my signature I certify that the above information is true.In the case of a minor patient, I certify I am the parent or legal guardian and consent to the treatment of said minor.I acknowledge being provided a copy of the Eyecare Center Of DuPage, Ltd. Privacy Policies in accordance with HIPAA regulations.I understand I am financially responsible for this account, regardless of any insurance coverage I may have.I agree to pay any collection costs, including agency and attorney fees, should they be incurred.All acknowledgements on this form apply to this visit and all future visits unless and until I notify the Eyecare Center Of DuPage, Ltd. of any revisions in writing.
Date*

MonthDayYear
Date
Signature - Please sign using your finger or mouse*

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Should be Empty:

	Father	Mother	Sibling	Other
Blindness
Cataract
Crossed-eyes
Macular degeneration
Retinal detachment/disease
Arthritis
Cancer
Diabetes
Heart disease
High blood pressure
Kidney disease
Lupus
Thyroid disease

	Yes	No
Do you Drive?
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?

	Yes	No
Does your spare pair have the current prescription?
Do your prescription sunglasses have UV protection?
Do you wear protective eyewear for sports or work?
Is the prescription in your computer glasses current?
Are there certain times you'd rather not wear glasses?

	Yes	No
Are you having any problems with your lenses?
Are you interested in new contact lens technologies?
Do you obtain your lenses legally?
Are your back-up glasses the current prescription?

	1	2	3	4	5
Vision
Comfort
Convenience
Cost
Health & safety

Welcome

Patient Information

Responsible Party/Guarantor Information

Referral Information

Insurance Information

Medical History

Please check any of the following conditions that apply to you:

REVIEW OF SYSTEMS & SOCIAL HISTORY (all negative unless indicated)

Please check any conditions you have currently or have had previously:

Current Corrections

If you wear orthokeratology retainers...

Eyecare Center of DuPage, Ltd. - INSURANCE AUTHORIZATION

Eyecare Center of DuPage, Ltd. - CONTRACT FOR CARE