Healthcare Optical Services Form

HEALTHCARE OPTICAL SERVICES FORM

Patient Information

Date of Birth:    Gender (check one): Male Female Other

Emergency Contact

Insurance Information

Subscriber Date of Birth:    Insurance Phone:

Medical & Ocular History

Do you have any of the following conditions? (check all that apply)
Diabetes Hypertension Glaucoma Cataract Autoimmune disease None of the above

Presenting Complaint / Symptoms

Examination Data (to be completed by clinician)

Distance Visual Acuity — OD:    OS:

Near Visual Acuity — OD:    OS:

Manifest Refraction — OD Sph: Cyl: Axis:

Manifest Refraction — OS Sph: Cyl: Axis:

Add power (if applicable) OD:    OS:

Contact Lens Evaluation (if applicable)

Current contact lens wearer: Yes No

Recommended Services & Fees

The following services are recommended and authorized by the patient where indicated. Fees not covered by insurance are the patient's responsibility.

Comprehensive Eye Exam    Fee: $

Spectacle Prescription & Dispensing    Estimated Fee: $

Contact Lens Fitting / Trial    Fee: $

Pharmacologic Dilation    Fee: $

Retinal / Anterior Segment Imaging    Fee: $

Consent for Optical Services

I, the undersigned patient or legal guardian, authorize the clinicians and staff of this practice to perform eye and vision examinations, diagnostic procedures, photography, retinal imaging, pharmacologic dilation, and contact lens evaluations as indicated. I understand that dilation and certain diagnostic procedures may cause temporary blurred vision and light sensitivity and that rare adverse reactions (such as allergic reaction to drops) can occur. I acknowledge that no guarantee has been made regarding the results or corrective outcomes of spectacles or contact lenses.

I understand that I may withdraw consent at any time prior to a procedure. If I decline a recommended procedure, I acknowledge that the clinician has explained the potential limitations to the assessment and subsequent care.

Consent for specific services (check applicable services you authorize):
Comprehensive Exam Dilation Contact Lens Fitting Imaging / Photography

Authorization to Release Health Information

I authorize release of my ocular and optical records, including exam results and imaging, to the following recipient(s) when necessary for care coordination or billing:

Purpose of Release:    Expiration Date:

I understand that once my records are released to the recipient named above, they may be subject to re-disclosure by that recipient and may no longer be protected under applicable privacy laws. I may revoke this authorization at any time in writing except to the extent that action has already been taken in reliance on it.

Financial Policy & Acknowledgment

I accept financial responsibility for charges not covered by insurance, including co-payments, deductibles, and non-covered services. Payment is due at the time of service unless other arrangements have been made in advance. Returned checks and collection costs will be the patient's responsibility.

Cancellation / No-Show Policy: Failure to attend a scheduled appointment without adequate notice may result in a fee. Repeated missed appointments may result in discharge from the practice.

HIPAA & Privacy Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices and understand how my health information may be used and disclosed. I authorize the practice to contact me regarding appointments, billing, and clinical matters at the contact information provided.

Communication preferences (check all that apply):
Phone Email SMS / Text

Certification: I certify that the information I have provided on this form is true and complete to the best of my knowledge. I agree to notify the practice of any changes to my medical history, medications, or insurance coverage.

Sign Now