mountainwesteyecare.com - New Patient Form

New Patient Form
Patient Information
Name

First NameLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Age
Primary Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Text Message Authorized

YesNo
Alt Phone
Please enter a valid phone number.
Email
example@example.com
Occupation/Grade
Spouse/Guardian
Referred by whom?
If you would like to give Mountain West Eyecare authorization to share your medical records with a family member or other individual, please complete the below information.

By Completing this Section, I Authorize the listed persons to have access to my medical records.
Name:
Phone Number:
Please enter a valid phone number.
Relationship to Patient:
If you enjoyed your visit or have any suggestions to make your time with us better, please feel free to call us and let us know, or leave us a review on Google.
Insurance Information
Vision Insurance
Subscriber Name
Subscriber SSN
Subscriber ID #
Subscriber Date of Birth

MonthDayYear
Date
Relationship To Patient
Medical Insurance
Subscriber Name
Subscriber SSN
Subscriber ID #
Subscriber Date of Birth

MonthDayYear
Date
Relationship To Patient
Flex Spending or HSA account

YesNo
Please be advised if you are using insurance for today's visit, this is a contract between you and your insurance company, not Mountain West Eyecare. Payment of all insurance co-pays, deductibles, and contact lens fees are required at the time of service. As a courtesy this office will submit most insurance claims to your provided insurance. However, the bill is your responsibility if your insurance company chooses to pay or not. Any fees not covered by your insurances in 60 days will be billed to you. Our Contact Lens Maintenance Plan will have additional fees that insurance will not cover and you will be held responsible for paying at the time of visit.

By signing below, I give permission to release information to 3rd party carriers (such as insurance companies) and do assign all insurance benefits for treatment and services to be paid directly to the provider at Mountain West Eyecare. I certify that a copy of this assignment wil be as valid as the original. I recognize that the provider cannot accept responsibility for collecting any insurance claim or negotiating any settlement on a disputed claim. I also agree that in the event of default in the payment of any amount due, and if this account is placed in the hands of an agency or attorney for collection or legal action, to pay the cost of collection including all accrued fees. I also confirm that I have read and understand all information on this form, and it is true and correct. And by signing this form I agree to pay all fees associated with today's visit.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

	Yes	No
Arthritis

	Yes	No
Anemia

	Yes	No
Seasonal

Should your account be turned over for collection, the undersigned agrees to pay all costs to collect the debt, including, but not limited to, interest in the amount of 18% per annum, attorney's fees, court costs, and collection fees in the amount of 40%. The obligation to pay the collection fees shall be imposed at the time of assignment of the debt to a third party debt collection agency.

Si acaso su cuenta sea enviada a colecciones, el que firmo el contrato se convendra a pagar todos los gastos para recuperar la deuda, incluyendo, pero no limitado a, interés en la cantidad de 18% por ano, cobros del abogado, costos judiciales, y cobros de colecciones en la cantidad de 40%. La obligacion para pagar las cuotas de colecciones serå impuesta al tiempo de asignacion de la deuda a una agencia de colecciones de deudas.
Guarantors Signature/ Garante Firma

Clear
Date/ Fechar

MonthDayYear
Date

Electronic Communications: I consent to receiving HIPAA-compliant communications from Mountain West Eyecare as well as its agents, subsidiaries, affiliates, officers, employees, partners, successors in interest, and any companies acting on its behalf. I may be contacted by live operator, dialing systems, prerecorded and artificial voice messages, text (SMS or MMS) or email at any time with information related to your account. I understand that this applies to me and anyone E have authorized to act on my behalf. I confirm I am the owner of or are authorized to use the provided numbers and email addresses. I will update any changes immediately. I understand that there is no obligation to receive these electronic communications. Messages/data rates may apply.

Comunicaciones Electronicas: Doy mi consentimiento para recibir comunicaciones compatibles con HIPAA por parte de Client Nameas, asi como sus agentes, subsidiarias, afiliadas, funcionarios, empleados, socios, sucesores de interés y cualquier empresa que actüe en su nombre. Puedo ser contactado por un operador en vivo, sistemas de marcacién, mensajes de voz pregrabados y artificiales, texto (SMS o MMS) o correo electrénico en cualquier momento con informacion relacionada con su cuenta. Entiendo que esto se aplica a mi y a cualquiera que haya autorizado a actuar en mi nombre. Confirmo que soy el propietario de o que estoy autorizado a utilizar los nümeros y direcciones de correo electrénico proporcionados. Actualizaré cualquier cambio inmediatamente. Entiendo que no hay obligacion de recibir estas comunicaciones electrönicas. Pueden aplicarse tarifas de mensajes/datos.
Guarantors Signature/ Garante Firma

Clear
Date/ Fechar

MonthDayYear
Date

Material Policy
It is the policy of Mountain West Eyecare that all services, including sunglasses, eyeglass frames, eyeglass lenses, and/or contact lenses, be paid in full prior to ordering.

Refunds will not be given on returned products. Upon full payment we begin your custom spectacle and/or contact lens order. For this reason, cancellations on spectacles and/or contact lenses are not permitted.

All glasses are custom crafted for each patient with their unique prescription and are not to be used or worn by others. Each prescription is valid for 1 year after date of examination unless deemed otherwise by the healthcare professional. All lenses are custom cut to fit each chosen frame purchased by the patient. Therefore, patients may not exchange frames after their lenses have been cut.

There will be a non refundable mounting fee charged for all orders using frames not purchased at the time of the lens order. Patients own frames cannot be warranted for breakage.

Refunds are not available on progressive lenses. However, patients who fail to adapt to or are dissatisfied with the new progressive lens, may be eligible for a one-time prescription remake at no additional charge, within the first 60 days from the date of purchase. After 60 days this warranty will expire and will not be honored.

Each contact lens prescription is specific to each patient individually and is valid for 2 years after date of exam unless reduced due to medical reasons, as determined by the providing healthcare professional. Contact lenses are not to be used or worn by others. Mountain West Eyecare does not warranty contact lenses. All contact lens warranties are determined by the individual manufacturer.

All materials (including but not limited to glasses, contacts, sunglasses, and other optical supplies) not collected within 6 months of their completion date will be deemed abandoned and discarded. No refunds will be given for abandoned materials.

I attest that I have read and understand the above policy and fees associated with eyeglass and/or contact lens purchases.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

	Yes	No
Loss of Vision
Blurred Vision
Double Vision
Pain/Itching/Burning
Flashes/FIoaters
Dry Eyes

	Yes	No
High Blood Pressure
Heart Disease
Stroke
High Cholesterol

	Yes	No
Thyroid
Kidney
Diabetes

	Yes	No
Depression
Anxiety
Schizophrenia
Bipolar

	Yes	No
Asthma
COPD
Emphysema

New Patient Form

Patient Information

Insurance Information

Vision Insurance

Medical Insurance

Medical History

Personal Health History

Family History

Material Policy

	Yes	No
Blindness
Cataract
Glaucoma
Crossed Eyes
Macular Degeneration
Cancer
Heart Disease
Kidney Disease
High Blood Pressure

	Yes	No
Fibromyalgia
Autism