Pediatric Patient Intake Form

Primary Vision Insurance
Insurance Name

Vision Service Plan (VSP)Vision Care Direct (VCD)No Vision InsuranceOther
Insurance ID:
Insurance Policy Group:
Is the patient the policy holder?

YesNo
If no, please provide the policy holder's information below:
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Gender
Relationship to Insured
Policy Holder's SSN
Full SSN or last 4 digits
Policy Holder's Employer
Phone Number
Optional: Upload front and back images of card

Browse Files

Cancelof

Medical Insurance
Insurance Name*

No Medical InsurancePresbyterianBlue Cross Blue ShieldCignaUnited HealthcareMedicareTricareOther
Insurance ID:*
Insurance Policy Group:
Policy Holder's SSN
Full SSN or last 4 digits
Upload front and back images of card*

Browse Files

Cancelof

Retinal Evaluation
Retinal Examination Options:
As part of your comprehensive eye exam, all patients receive an Optomap photograph or dilation for retinal evaluation:

Optomap:
- Ages 6–18: Optomap is the standard method, providing advanced imaging, early disease detection, and a record for future comparison.
Dilation:
- Ages 5 and younger: Dilation with drops is required for accurate developmental analysis.
Note: Some patients over 5 may also require dilation based on the doctor’s findings.

By continuing, you acknowledge the information provided about retinal evaluation methods.
A retinal evaluation is required for all exams. Please select one of the following options:*

Optomap (Ages 6 - 18)Dilation (5 and younger)

Contact Lenses
Do you need a contact lens prescription?

Yes - Service fee is $250 or VSP CopayNo, but interestedNo, not interested

If you are a current contact lens wearer:

	Answers
What brand of contacts do you wear?
How often do you sleep in your contacts?
How often do you replace your contacts?
Do you have back up glasses?

Online Patient Form