INTAKE FORM 5.24

We're located inside the Elkridge Costco

Our office is NEXT to the Optical Department. Costco membership is not required for the exam. However, membership is required to purchase glasses/contact lenses.
If you need to cancel or reschedule, contact our office 24 hours before your appointment. Otherwise, we do charge a $50 late cancellation or no-show fee.

Upon arrival, if you are sick and have contagious symptoms, you may be required to wear a mask or cancel/reschedule your appointment. For the safety of our staff and patients, we would appreciate if you call to cancel if you exhibit any symptoms.
If you have already scheduled an appointment, please let us know the date and time of your appointment*

MonthDayYear
Date
Hour MinutesAM/PM Option
If you have not schedule an appointment, please use this LINK TO SCHEDULE and return to this form after scheduling.

PATIENT INFORMATION
Legal Name*

First NameMiddle NameLast Name
OPTIONAL: Preferred First Name
Optional
Date

MonthDayYear
Date
Birthdate*

MonthDayYear
Date of Birth
Days
Age
Guardian Name (if under 18)*

First NameLast Name
Biological Sex*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
We do not spam or share your info
Home Phone Number
We do not spam or share your info
Email*
Providing an email allows us the permission to send appointment reminders, invoices, and copies of your prescription(s). We do not spam or share your info
Occupation*
So we may understand your daily visual needs

OPTOMAP RETINAL EXAM
Our doctors highly recommend the Optomap Retinal Screening to all of their patients, of any age and each year, for the following reasons:
- it is a non-invasive technique to examine the health of your eye, without the side effects of drops or blurry vision
- it provides a high resolution picture, that can be compared with future scans
- it contributes to our standard of care and improves patient education and satisfaction.
There is a nominal fee of $35 for this test.

I have read this and understand that a wide field view of the retina is an important part of a comprehensive eye exam.
Please choose an option*

I would like to have the OPTOMAP exam for $35.IF NECESSARY, I prefer DILATION, which has side-effects of blurred vision and light sensitivity ($35).

OFFICE POLICIES and NOTICE OF PRIVACY POLICIES
Prescription re-checks: If you have problems with your glasses, we provide complimentary re-checks within 3 months of your exam date. Keep in mind, if no changes are found, a $40 troubleshooting fee will be charged.

Contact Lens evaluations: include sample diagnostic lenses and up to 3 follow-up visits within 2 months (as needed). Problems beyond 3 months incur additional exam fees, beyond 6 months require a new exam. New wearers require a training course.

Electronic communications: you allow us to email/SMS appointment reminders, electronic copies of prescriptions, invoices, receipts, etc. We do not share your data.

$50 no-show / same day cancel fee: arriving too late may require rescheduling, not showing up or cancelling on the day of your appointment, will result in a $50 fee; which must be paid before another appointment is scheduled.

Payment: is due at the conclusion of the exam. I understand that information obtained from my vision plan and/or medical insurance on my behalf, is not a guarantee of payment or benefits, and that I am obligated to pay any portion of office fees not covered by my insurance company.

Advanced Beneficianry Notice of Non-Coverage: Medicare and some insurances may not cover services such as Optos retinal screening photos, contact lens evaluations, or refractions. These fees are listed on our website and reviewed with patients. If you receive these services, you agree that we can not bill your insurance for them and you accept responsibility for the fees.
The listed individuals are authorized to receive my protected health information (such as my prescriptions). I am aware that I can revoke the authorization at any time, but must do so in writing.*

Spouse / PartnerChildrenParentNobodyOther
By pressing submit, I acknowledge I have read the entirety of this form, am aware and agree to the office policies of DR JAN EYE CARE, and have reviewed their HIPAA privacy policies available HERE.
Name*
Signature*

Powered by Jotform SignClear
Should be Empty:

We're located inside the Elkridge Costco

If you have not schedule an appointment, please use this LINK TO SCHEDULE and return to this form after scheduling.

PATIENT INFORMATION

Billing Information

Health History

OPTOMAP RETINAL EXAM

OFFICE POLICIES and NOTICE OF PRIVACY POLICIES