Patient Registration Form

Patient Information

Insurance Policy Holder’s Information:

Reason for Today’s Visit:

Patient & Family Medical/Eye History:

In addition to the basic routine eye exam for glasses or contact lenses, our doctors strongly recommend routine retinal screening test (Optomap). The Optomap allows your eye doctor to evaluate the health of the back of your eye, to detect and measure any changes to your retina each year you get your eye examined. It is critical to confirm the health of the retina, optic nerve and other retinal structures. Many eye diseases, if detected at an early stage, can be treated successfully without total loss of vision. Don’t hesitate to ask about the fee for your routine retinal screening test.

We are required by law to maintain the privacy of your health information. The privacy notice can be provided to you upon request. We will not use or disclose any medical information about you without written authorization, except as described by the notice. By signing below, you acknowledge that you have received and have had the opportunity to review the Privacy Notice.

Payment Responsibility: Professional Fees are NON-REFUNDABLE Sorry, We DO NOT accept Checks

​​​​​​​I understand that authorization from insurance does not guarantee payment. The office may bill the balance due to patient. I, (the patient or guardian), are responsible for all fees whether covered, or not paid/ reimbursed by my insurance carrier. I, (the patient or guardian) have read and agree to Vision Source Spring Notice of Privacy Practices and the Office’s Polices.