Patient History/Authorization for Payment/Contact Lens Examination and Retinal Imaging Fees

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Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

Prefix First Last Suffix

Address*

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

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Email Address

Please provide us your email address.

Personal Information

Gender*

Female

Male

Date of Birth*

Preferred Language*

Marital Status

Marital Status - Other

Please provide your marital status.

Occupation*

Employer

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Communication Preference

Eye History

Please check off any current conditions you suffer from

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Glasses History

Do you wear glasses?*

Yes

What glasses do you own?

Single Vision

Bifocals

Safety Glasses

Backup Glasses

Progressive

Trifocals

Sports Glasses

Sunglasses

Other

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

Please enter a number from 0 to 24.

How many inches away, approximately, do you sit from your computer monitor?

Please enter a number from 0 to 120.

Please check off any current conditions you suffer from

I am having problems with my current glasses

There are times when I would rather not be wearing glasses

I have problems with glare

I have problems with night vision

I am allergic to nickel (e.g. frames of glasses)

I don’t have spare set of glasses

My spare glasses have an incorrect prescription

My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses?*

Yes

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

Please enter a number from 0 to 24.

What is your typical wearing schedule? In days per week:

Please enter a number from 0 to 7.

Please check off all that apply to you

I am having problems with my current contact lenses

There are times when I would rather not be wearing contact lenses

I am interested in changing or enhancing my eye color

I am interested in a non-surgical method of vision correction

I am interested in refractive laser surgery

I don't have a spare set of contact lenses

My spare contact lenses have an incorrect prescription

Medical History

Reason for the visit?*

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician? (or indicate "none")*

Do you drink alcohol?

Do you smoke?*

Please list all medical conditions you have ever had (diabetes, high blood pressure, arthritis, etc., or indicate "none"))*

Please list any eye conditions you have ever had (ie: injury, surgery, glaucoma, cataract, crossed or lazy eye, retinal detachment)*

Please list any medical or eye conditions that run in your family (ie: diabetes, high blood pressure, cancer, glaucoma, macular degeneration; or indicate "none")*

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions (or indicate "none")*

Please list all drug allergies you have (or indicate "none")

Please check off any current conditions you suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name*

Insured's Name

First Last

Identification Number*

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name*

Insured's Name

First Last

Identification Number*

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

If you have any comments you would like to add, please enter them here.

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Payment for Services, Patient Financial Responsibility, and Authorization Statement

We would like to welcome you to our office and inform you of our policy regarding fees. We are committed to providing the best quality eye care. In order to achieve this goal, we need your assistance and understanding of our payment policy. We will gladly discuss any questions you may have, and appreciate the opportunity to serve you.

Payment for Services:

Eye Care Center participates with many medical insurances and vision plans. Evidence of active coverage is required at the time of service (by providing us with insurance card or ID number) or payment will be due on the date of service.
Payment for all services and products is the responsibility of the patient and due at time of service.
Your eye care benefit is a contract between you, your employer and the insurance company. We are not a party to that contract and this office will file your claims as a courtesy to you.
Not all services are a covered benefit in all contracts. It is your responsibility to know your benefits.
We accept cash, checks and all major credit cards, including FSA/HSA benefit cards.

Patient Financial Agreements:

I agree to pay all copays, deductibles, co-insurances, and non-covered services as determined by my insurance company.
I agree to pay balances due in a timely manner or incur additional collection fee for past due accounts.
I authorize the release of medical information concerning my illness and treatment to my insurance company.
I authorize the release of my personal medical information to any doctor whom I may be referred to.
I understand verification of eligibility is not a guarantee of payment as stated by my insurance company.

Authorization Statement:

I authorize payment of my insurance benefits to Eye Care Center, Dr. Amanda Hale, O.D.

Financial agreement authorization*

I have read and acknowledge the Financial Agreement and Authorization Statement.

Contact Lens Examination and Retinal Imaging Fees

Contact Lens Examination: Because contact lenses are considered medical devices by the FDA, they must be monitored every year to ensure safe and healthy wear. Our goal is to ensure your eyes stay healthy and you achieve the best vision possible with your contact lenses. This means that, in addition to your routine eye exam, extra testing is required for all contact lens wearers. During your contact lens evaluation, the doctor and staff check:

The health of your cornea, eyelids, and lashes
How well your lenses fit
The quality of your vision with your lenses

These steps require specialized equipment, additional time, and professional expertise. For new wearers, the fee also includes training on insertion and removal, initial solutions, and diagnostic trial lenses.
Contact Lens Professional Fee: $75–$110 (Depending on lens type; in addition to routine exam fees.
If you do not have routine exam coverage, a self-pay exam including retinal imaging and the contact lens evaluation is $150.
Digital Widefield Retinal Imaging
To provide you with the most thorough and advanced eye care, Dr. Hale now offers digital widefield retinal imaging as an important part of your eye exam. This technology captures a detailed picture of the inside of your eye, giving the doctor a clearer, more complete view of your retinal health than traditional methods alone. Many eye conditions—such as macular degeneration, glaucoma, retinal tears or detachments, and even systemic health issues like diabetes and high blood pressure—can develop without any symptoms. Retinal imaging helps identify these problems sooner, when treatment is most effective. Why this image is valuable:

High-resolution scan: Confirms a healthy eye or helps detect early signs of disease.
Wider view of the retina: Allows the doctor to see areas that are otherwise difficult to examine.
Better understanding of your eye health: You can view and discuss the images with your doctor.
Permanent record: Stored in your medical file to compare changes over time and catch issues earlier.

This advanced imaging is available to all patients for a $39 copay.

Retinal Photos Consent*

Yes, I would like to have the retinal images taken to give the doctor the most complete view of my eye health.

I prefer to decline retinal images today and will proceed only if the doctor recommends them.

Name of Patient or Legal Guardian

First Last

Signature

Date

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Phone

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Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy

Payment for Services, Patient Financial Responsibility, and Authorization Statement

Contact Lens Examination and Retinal Imaging Fees

Eye Care Center