PATIENT INFORMATION

Make an Appointment

Re-Order Contacts

OFFICE HOURS

M 8:30 AM – 5:00 PM

T 8:30 AM – 5:00 PM

W 8:30 AM – 1:00 PM

T 8:30 AM – 5:00 PM

F 8:30 AM – 5:00 PM

Fill out our Patient Forms

Patient Form

Today's Date*

Name:*

First

Last

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Home Phone:

Work Phone

Cell*

Email:

Date of Birth*

day

month

year

Last 4 digits of Social Security#?*

Sex*

Employer or School*

Occupation or Grade*

Spouse or Parent Name*

First

Last

If patient is a minor, who is responsible for payment of the bill?*

First

Last

Referrals are our greatest compliment. We enjoy thanking referrers with a gift card to Starbucks, Wawa or AMC. Please let any friends, family or co-workers you refer in let us know your name!

Whom may we thank for referring you to our office?

First

Last

Insurance Information

Vision Insurance*

Medical Insurance*

Policy Holder's Name*

First

Last

Policy Holder's Date of Birth*

day

month

year

Main reason for your visit?*

Do you wear contacts?*

If “Yes”, our goal is all day comfort with your contacts. What would you describe as your comfort level?

Do you wear reading glasses? Play sports? Don’t always want to wear glasses? Contacts may be a perfect fit for your lifestyle. Great advances have been made in areas of both comfort and vision, including “multi-focal” contacts, these are contacts worn for both near and far visual needs – we can discuss this option today.

Medical History

Glaucoma - Self*

Glaucoma - Blood Relative*

Diabetes - Self*

Diabetes - Blood Relative*

High Cholesterol - Self*

High Cholesterol - Blood Relative*

Thyroid - Self*

Thyroid - Blood Relative *

Cataracts - Self *

Cataracts - Blood Relative*

High Blood Pressure - Self*

High Blood Pressure - Blood Relative*

Headaches*

Itchy Eyes *

Redness*

Dry Eyes*

Excessive Tears*

Light Sensitivity *

Do you smoke?*

Do you drink alcohol? *

If yes, how often do you drink?

Any major surgery or illness?*

If yes, please list your surgery(s) or illness?*

Are you allergic to any medications?*

If yes, please list medications*

List any medications you are taking*

I authorize Orlando Eyecare to file a claim for today’s visit with my insurance company, if appropriate. If so, I will be responsible for all charges that are not covered or paid by my policy. I am aware that the contact lens fitting and follow up care may not be covered under the “exam” definition of my policy.

Signature*

Please read and initial at the end of each statement…

Orlando Eyecare Financial Policy

Thank you for choosing Orlando Eyecare as your eye care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment plan. The following statements in regards to our Financial Policy are required to be read and signed prior to any treatment.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE.WE ACCEPT: CASH, CHECKS, VISA, MASTERCARD,DISCOVER AND CARE CREDIT.

Regarding Insurance:

We will file your insurance as a courtesy to you, but if no payment has been made from your insurance company within 60 days, the current balance remaining becomes the responsibility of you, the patient (or guarantor). The balance is your responsibility whether your insurance company pays a portion or not. We cannot bill your insurance company unless you give us your correct insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party in that contract. Please be aware that some, perhaps all, of the services provide may be non-covered services and not considered reasonable and necessary under Medicare and /or other medical insurance.

Signature (Regarding Insurance)*

Usual & Customary Rates

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Signature (Usual & Customary Rates)*

Minor Patients

The adult accompanying a minor and the parents (or guardian of the minor) are responsible for payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit card, or payment made by cash or check and the time of the visit.

Signature (Minor Patients)*

Thank you for reading our Financial Policy. Please let us know if you have any questions or concerns.

I have read the Orlando Eyecare Financial Policy and I understand and agree to the terms.

Signature of Patient/Responsible Party*

Date (Patient/Responsible Party)*

Word Verification

Eyewear

We only carry quality, durable, and stylish frames that have stood the test of time and reputation.

Contacts

We offer a variety of contacts, sure to meet requirements for every lifestyle.

EYE EXAMS

You will receive the latest, and best that is available in total eye health. We will provide you with the knowledge you need to make informed decisions