New Patient Form

As a part of your eye exam today, we will be capturing high resolution imaging and scans of the back of your eye with our advanced retinal camera and our optical coherence topographer (OCT). This technology has become the new standard of care for optometry, giving Dr. Cleveland and Dr. Blake invaluable images for the earliest diagnosis, documentation and monitoring of any systemic or sight threatening conditions.

​​​​​​​This imaging is to be performed on all patients above 5 years of age, regardless of history. It is fast, simple, and non invasive, but can provide critical insights into your ocular health in conjunction with dilation. These screener photos and OCT scans for diagnostic purposes are not covered by vision or medical insurance, and the cost for these services is $54.

In some cases, we need to capture medically focused images or scans based on history and diagnoses. These will be billed to your major medical insurance at a different rate.

*OCT scans may be omitted and performed on a schedule of every 5 years based on your personal history, family history, risk factors and age at the doctor’s discretion. In these instances only retinal screening photos will be captured at a cost of $39.

** In addition to these screenings, dilation is performed on all new patients on the day of their comprehensive exam.

Vision plans, such as VSP provide discounts for wellness exams, prescriptions for eyeglasses and contact lens services. During the course of your exam, the doctor may encounter symptoms or diagnose a medical condition that falls outside of what is considered routine vision care. This can also be based upon information you provide to us, or pre-existing diagnoses and medical conditions. Common examples are allergies, dry eye, headache, cataracts, glaucoma, and diabetes among others. In these cases we will bill your major medical insurance, and you are responsible for any applicable copays or deductibles. If you have both types of insurance, we can coordinate your benefits, when applicable, to minimize your out of pocket expense.

If you do not have vision or major medical insurance, payment is expected in full at the time of service. We do accept partial payments on eyeglass orders.

Please note we have a 24 hour cancellation policy. If you do not cancel within 24 hours of your appointment, there is a $30 non-refundable cancellation fee.

Unpaid balances will be sent to collections after 90 days. In the event your account is sent to collections an additional fee of 40% of the balance will be applied for services rendered to the collections agency. The agency may contact you via email, text message, phone call or physical mail. If you have previously been sent to collections we require payment prior to future appointments. Should we receive payment from your insurance, we will apply the amount previously paid towards any copays or deductibles, and refund remaining overages.

Please note that if you are the parent/guardian who is escorting a minor to their appointment, you are financially responsible for any balances incurred on the date of service. This policy applies regardless of custody/marital agreements.

​​​​​​​By signing below, you are acknowledging receipt of our privacy policy, our financial policy, and our cancellation policy. You are also giving Perimeter West Eye Care authorization to release your medical information as necessary to expedite insurance claims, or share appropriate information with your other medical providers as requested.