Intake Form

Patient Demographics
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Guardian name, if applicable
MaleFemaleOther
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When was your last eye exam*

MonthDayYear
Feel free to give a rough estimate
Is there an aspect of your vision that you would like to improve?
Are you interested in contact lenses today?
Do you suffer from migraines?
Insurance Name
Please Type 0 if no insurance
Insurance Group#
Please Type 0 if no insurance
Insurance Member ID
Please Type 0 if no insurance
Primary Member Information

First NameLast Name
Primary Member Information

MonthDayYear
DOB
Primary's Last 4 numbers of social security#
Patients relationship to Primary
Insurance and State ID upload
Take Photo of the front and back side of your vision AND medical insurance

Cancelof
Take Photo of the front and back side of your STATE ID*

Cancelof
General Medical History
List any current medication:
List any allergies:
List any ocular history such as surgery or trauma:*
Type 0 if no previous ocular history
List any family ocular history:
Type 0 if no previous family ocular history
YesNo
YesNo
Please print your initials here to confirm that you have completed the above questions accurately.*
Checking the inside health of your eyes (Optomap vs Dilation)
At Everyone Eyecare, we do more than just check your glasses prescription—we also look at the overall health of your eyes. Your eye exam can help detect early signs of eye diseases and even some general health conditions.

To examine the inside of your eyes, we use either Optomap imaging or dilation. Both methods allow us to get a complete picture of your eye health.

Regular eye health checkups are important for everyone, no matter your age. It’s recommended to have an Optomap or dilation every year as part of your routine eye exam.

For first-time patients, we recommend an Optomap. It gives us a clear photo of your eyes that we can use as a reference for future exams.
Yes, I would like to complete the OptomapYes, I would like to complete the dilationI would like to discuss this further with the doctor.
Dry Eye Questionaire
0 - Never1 - Rarely2 - Sometimes3 - Frequently4 - Constantly
0 - None1 - Mild2 - Moderate3 - Severe4 - Very Severe
0 - Never1 - Rarely2 - Sometimes3 - Frequently4 - Constantly
0 - None1 - Mild2 - Moderate3 - Severe4 - Very Severe
0 - Never1 - Rarely2 - Sometimes3 - Frequently4 - Constantly
Financial Responsibility Agreement
Co-Payments: I understand that all co-payments must be paid in full at the time of service.

Deductible: If my deductible has not been met, I am responsible for the full payment before leaving.

Vision Exam vs Medical Exam: If my vision plan is used for an exam that is later classified as medical, I may need to use my medical insurance or pay out-of-pocket.

Denial or Non-Coverage: I accept full financial responsibility for any services not covered or denied by my insurance. I have reviewed and understand these terms.
Please print your initials here to confirm that you have completed the above questions accurately.*
Cancellation Policy
- At Everyone Eyecare we value your time and ask for at least 24 hours' notice for cancellations or rescheduling so we can accommodate other patients. A $40 deposit is required for any additional exams or recommended tests.
- The deposit can be used toward your exam fees or copays.
- If you cancel, reschedule, or miss your appointment without 24 hours' notice, the deposit will be used as a no-show fee.
- Call or text us anytime at 830-357-0736. After hours, leave a voicemail or text. Please use only this number and avoid replying to automated reminders.
Please print your initials here to confirm that you understand and have read our cancellation policy.*
60 Day Return Policy
Prescription Guarantee Policy

If you have any issues with your new glasses or contact lens prescription, you may return for a follow-up or adjustment within 60 days of your initial visit at no extra charge.

After 60 days, any further exam services will require medical insurance or out-of-pocket payment.
Please print your initials here to confirm that you understand and have read our 60 day return policy.*
HIPAA Compliance Patient Consent Form
A HIPAA consent form gives us permission to share your health information with other healthcare providers, insurance companies, or anyone involved in your care while keeping your information private and secure.

(Please let us know if you would like to request full HIPAA form, that further explains this conset form in detail)
Please print your initials here to confirm that you understand and have read our HIPAA Compliance Patient Consent Form.*
I have read and understand the documents above and confirm that the information I have provided is accurate to the best of my knowledge.
Print your name*
Date*

MonthDayYear
Date
Signature*

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Patient Demographics

Insurance and State ID upload

General Medical History

Checking the inside health of your eyes (Optomap vs Dilation)

Dry Eye Questionaire

Financial Responsibility Agreement

Cancellation Policy

60 Day Return Policy

HIPAA Compliance Patient Consent Form

I have read and understand the documents above and confirm that the information I have provided is accurate to the best of my knowledge.