Pediatric Patient Intake Form

Pediatric Patient Intake Form

Online Patient Form
Full Name

First NameMiddle InitialLast NameSuffix
Nickname
Date of Birth

MonthDayYear
Birth Sex
Address

Street Address

Street Address Line 2 /Unit no.

CityState

Zip Code
Cell Number
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.
E-mail
Preferred Contact Method
Pronouns
Student Grade Level
School Name
Misc/Guardian

Billing Information
Responsible Party's Name

First NameLast Name
Is the billing address the same address as the patient?
If no, please provide the responsible party's information below:
Phone Number
Format: (000) 000-0000.
Relationship to Insured
Address

Street Address

Street Address Line 2

CityState

Zip Code

Primary Vision Insurance
Insurance Name
Insurance ID:
Insurance Policy Group:
Is the patient the policy holder?
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
Format: (000) 000-0000.
Optional: Upload front and back images of card

Browse Files

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Medical Insurance
Insurance Name
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:

Contact Lenses
Do you need a contact lens prescription?

If you are a current contact lens wearer:

Rows	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?

Individuals Authorized to Access My Medical Records
Name

First NameLast Name
Individual's Name and Relationship
Name

First NameLast Name
Individual's Name and Relationship

Patient Policies and Forms Review
Please review the following policies and forms before signing below to acknowledge your understanding and agreement. Each document is linked for your convenience.

No-Show Policy
Appointments missed without prior notice are subject to a $50 rescheduling fee. Patients with Medicaid will not be charged; however, they will be unable to schedule new appointments until the next calendar year.

Notice of Privacy Policy

Our commitment to protecting your privacy and handling your personal information with care.

Patient Rights & Responsibilities
An overview of your rights and responsibilities as a patient receiving care at City of Vision Eye Care.

Medical Release Form

Authorization for the release of your medical records to designated individuals or healthcare providers.

Unattended Minor Patients (Policy & Form)

Guidelines and consent form for providing care to minors when a parent or legal guardian is not present.

Financial Policy

Information on accepted payment methods, insurance billing, self-pay accounts, and financial obligations related to your care.

If you have any questions or need clarification regarding any of these documents, our staff will be happy to assist you.
Signature
Date

MonthDayYear
Date
Should be Empty: