Pre-appointment form with address

Pre-Appointment Form

Please review all sections carefully, and sign.
Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Email: your patient portal will be linked to this e-mail*
example@example.com
Has your address or phone number changed?*

No (skip to the next section)Yes (please update your new information below)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number

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WHAT IS DILATION or OPTOMAP IMAGING?

These procedures allow for the thorough examination of the internal health of your eyes and signs of other diseases (for example hypertension, diabetes, glaucoma, etc.). Without one of these procedures, your eye doctor only sees about 30% or less of the eye’s interior surface, leaving potential problems undetected. Early detection is crucial to saving your sight, as many early eye diseases are asymptomatic.
- PUPIL DILATION: is the process of administering eye drops in order to enlarge the pupils temporarily. This allows an eye doctor to have greater view of the inside of the eye. It will cause your vision to be blurred, primarily up close, as well as light sensitive for approximately 3-5 hours. This procedure will add an additional 30 minutes to your eye examination.
- OPTOMAP (OPTOS) RETINAL IMAGING: is an ultra-widefield image of the retina. This allows for the similar evaluation as the dilation, but WITHOUT the inconvenient side effects of dilation drops and only takes a few minutes. These images are saved and able to be compared year after year, making it easy to see changes that may occur. NOTE: in some cases, dilation may also be medically indicated.
Decision Time: please check the following*

Yes, I would like the DILATION. There is NO additional charge.Yes, I would like the (NO DROPS) OPTOMAP imaging. The fee is $39. (Dr. Vo strongly recommends this test since the images are saved to your file, enabling her to make important comparison during your annual eye exam).I would like to discuss further with the doctor
iWELLNESS SCAN - is a high-resolution cross-sectional scan, which provides detailed images beneath the surface of the retina that otherwise cannot be visible (like an MRI of the eye). The scan assists Dr. Vo with early detection of retinal/macular abnormalities and vision threatening pathologies before such diseases are visible through a traditional eye exam.
Decision time: please check one of the following*

Yes, I would like to have the iWellness today. The fee is $30.No, I am declining the iWellness scan.I would like to discuss further with the doctor

OFFICE POLICIES

-Professional services such as routine exam, contact lens evaluation, specialty testing, medical eye procedure, and other office visits are non-refundable. All professional fees are due and payable at the time service.

-In some cases, your glasses prescription may need to be tweaked after your eyeglasses are made. If you experience any discomfort or blur that lasts longer than a week of continual wear, we are happy to re-evaluate your prescription to see if any changes need to be made and reorder your updated lenses at no charge. We want you to see clearly! You have 60 days from the date of purchase to contact our office.

-If a courtesy spectacle recheck is needed, it must be done within 2 months from your initial exam. Any contact lens follow-ups will be covered by the contact lens fit/evaluation fee, but it must be done within 2 months of your initial exam to avoid any late follow-up fees.

-Prescription lenses are considered custom orders. Your lenses are cut and designed uniquely for you and your eyes, and for your chosen frame. We will do our best to resolve any issues you may have with your spectacles. Returns are subject to a restocking fee of 15% of the cost of the frame plus lenses before insurance and discounts, if any.

-Glasses returns are only accepted within 15 days (including non-business days) from the date of dispense. Returns must be free of defect & damage. At our discretion, we may deny returns of damaged frames and lenses.

-If glasses are not picked up or paid in full by 60 days after your glasses are ready, any deposits and/or insurance benefits will be forfeited, and your order will be cancelled.

-If your contact lens prescription have changed, we will gladly exchange contact lenses purchased from our office. We can only accept unopened and undamaged contact lens boxes and the exchange must be within 6 months from the date of purchase. Only valid with purchases made at our office.

-Contact lens returns are only accepted within 30 days upon pick up. Boxes must be unopened and unmarked in sellable condition.

-Your appointment slot is reserved for you. If you are unable to keep the appointment, please be advised that we do require 24-hour notice to avoid $40 Late-Cancellation fees for any rescheduled or cancelled appointments.

-We utilize Patient Health Portal to upload necessary documents. Once glasses or contact lens prescription is finalized, it will be uploaded to your patient portal. Once uploaded, you will get a notification via e-mail.
Patient / Guardian Initials:*
ASSIGNMENT OF BENEFITS

I, the undersigned, certify that I (or my dependent) have insurance coverage with the insurance plan(s) provided and assign directly to Concept Eyecare, PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by the insurance and that professional fees are non-refundable. Concept Eyecare will make every effort to verify my insurance plan(s) and to collect only the amount due at the time of service. However, this is only an estimate, and I may have a remaining portion to pay as a copay, co-insurance, or deductible after my claim is processed. I understand that my vision and/or health insurance coverage is a contract between myself and my insurance company and that it is ultimately my responsibility as the patient to understand my insurance coverage as well as handle any charges my plan does not cover.
Explanation of coverage: Vision Plans versus Medical Insurance
I acknowledge understanding of the information above and authorize Concept Eyecare to file claim(s) with my appropriate insurance(s). My initials below constitute my understanding of this explanation of coverage and assignment of benefits.
Patient / Guardian Initials:*
NOTICE OF PRIVACY PRACTICES

I acknowledge that I have read the Notice of Privacy Practices, as mandated by the Health Portability and Accountability Act "HIPAA" (see below). I also consent to the use and disclosure of my information to only carry out treatments, payment activities, and submission of insurances.
Patient / Guardian Initials*
Consent for use and disclosure of information:

Due to HIPAA regulations, if you are over 18 years of age, please list any authorized person(s) with whom we can discuss your personal health information (Example: spouse, parent, etc.)
Name
Relationship to Patient
Name
Relationship to Patient

ACKNOWLEDGEMENT:

I have read the above information and understand statements regarding insurance assignment of benefits, privacy policy, and financial/office policies. I acknowledge that my spectacle and contact lens prescription will be available on the patient portal, and I understand how to access the Patient Health Portal with Concept Eyecare. As a patient, I have the right to voice any concern regarding any of the above statements. By signing below, I have read and understand Concept Eyecare’s policies.
Signature (patient or representative)*

Clear
Printed Name*
Date*

MonthDayYear
Date
NEW PATIENTS ONLY:

To save time save and to make the office administration process easier, please visit our website (https://concepteyecare.com/patient-center-copy) to fill out the "New Patient History Form" in addition to this "Pre-appointment form" prior to your arrival.
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Pre-Appointment Form

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