New Patient Form | Information Form for New Eyecare Patients

Thank you for choosing our practice for your eye care needs. Please complete the following. If you have any questions or concerns, please do not hesitate to ask for assistance. To prevent any misunderstandings, we have a stated payment policy. Payment in full is expected at the time services are provided. Payment may be made with cash, check, Mastercard, Visa, Discover, or an insurance program for which we accept assignment. If eyeglasses or contact lenses are to be ordered we require payment in full. Any balance owed must be paid in full when materials are dispensed.

Patient Information

Name*

Prefix First Middle Last

Nickname

Sex Assigned At Birth*

Male
Female

Gender Identity

Male
Female
Non Binary

Preferred Pronouns

He/Him/His
She/Her/Hers
They/Them/Theirs

Home Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Secondary Phone

Email*

What is your contact preference?

Phone
Email
Text

DOB*

Occupation*

Employer*

Spouse/Parent's Name (if minor)

Spouse/Parent's Employer (if minor)

I authorize Perimeter West Eye Care to release my medical and/or billing information to the following individuals:

Name

Relationship

Name

Relationship

Name

Relationship

Signature – Information*

Insurance Information

A copy of your card will be required.

Do you have medical health insurance?

Yes
No

Vision Discount Plan

(VSP, Eyemed, Blue View Vision, Cigna Vision etc.)

Vision Service Plan (VSP)
None

As of 11/01/2017 EyeMed changed their policies and no longer allows us to utilize routine vision benefits when billing medically (coordinate benefits). Additionally, in a few cases, it may also affect your contact lens service fees. Please contact our office, 614-789-5559, if you have any questions prior to your appointment.

Medical Insurance

Name of Primary Insured*

Date of Birth of Primary Insured*

Primary Insured's Last Four Digits of SSN*

Relationship to Patient*

Authorization

Must be signed for insurance purposes.

I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.

Signature – Authorization*

Privacy Notice

I acknowledge I have received a copy of Perimeter West Eye Care’s Financial Policy and Privacy Policy.

Signature – Privacy and Financial Policy*

Date*

Whom may we thank for referring you to our office?

What brings you in today? (Please check all that apply)

Glasses
Contact Lenses
Dr. Requested Follow-Up
Eye Allergies
Eye Irritation
Eye Infection
Headaches
Flashes/Floaters
Lasik Consultation

Ocular Symptoms (Please check all that apply)

Patient's Medical Health History

Patient's Ocular Health History (Please check all that apply)

Eye Injuries/Surgeries

Eye Medications/Drops

Full Name of Your Primary Care Physician

Family's Medical Health History

Has anyone in your immediate family suffered from:

Dry Eyes

Yes
No

Relationship to patient

Eye Injuries

Yes
No

Relationship to patient

Strabismus (Eye Turns)

Yes
No

Relationship to patient

Blindness

Yes
No

Relationship to patient

Cataracts

Yes
No

Relationship to patient

Glaucoma

Yes
No

Relationship to patient

Retinal Detachment

Yes
No

Relationship to patient

Keratoconus

Yes
No

Relationship to patient

Color Vision Problems

Yes
No

Relationship to patient

Amblyopia (Lazy Eye)

Yes
No

Relationship to patient

Macular Degeneration

Yes
No

Relationship to patient

Has anyone in your immediate family been diagnosed with Cancer?

Yes
No

Type? Relationship to patient

Has anyone in your immediate family been diagnosed with Diabetes?

Yes
No

Type 1 or Type 2? Relationship to patient

Has anyone in your immediate family been diagnosed with Hypertension?

Yes
No

Relationship to patient

Has anyone in your immediate family been diagnosed with Thyroid Disorder?

Yes
No

Relationship to patient

Other relevant medical history in your immediate family?

Yes
No

Explanation of Problem

Review of Systems

Constitutional (changes in weight, sleep)

Yes
No

Explanation of Problems

Ear, Nose, Throat

Yes
No

Explanation of Problems

Neurology (headaches, MS, tumors)

Yes
No

Explanation of Problems

Psychiatric (depression, anxiety, ADD, autism)

Yes
No

Explanation of Problems

Cardiovascular (heart disease, high blood pressure)

Yes
No

Explanation of Problems

Respiratory (asthma, emphysema)

Yes
No

Explanation of Problems

Gastrointestinal (ulcers, reflux, IBS)

Yes
No

Explanation of Problems

Genitourinary (genitals, kidneys, bladder)

Yes
No

Explanation of Problems

Bones/Joints/Muscles (arthritis, MD)

Yes
No

Explanation of Problems

Skin Disorders (rosacea, lupus)

Yes
No

Explanation of Problems

Blood/Lymph

Yes
No

Explanation of Problems

Allergy (seasonal, foods, medications)

Yes
No

Explanation of Problems

Cancer

Yes
No

Explanation of Problems

Currently Pregnant

Yes
No

Explanation

Currently Nursing

Yes
No

Explanation

Endocrine (diabetes, thyroid)

Yes
No

Last Hemoglobin A1C?

How frequently do you see your endocrinologist?

Full name of endocrinologist?

List all medications, supplements, and over the counter medicine you take on a routine basis.

Are you allergic to any medications?

Yes
No

List all medication allergies.

Social History

Do you use tobacco products?

Yes
No

Type/Amount/How Long?

Do you drink alcohol?

Yes
No

Type/Amount/How Long?

Informed Consent for Eye Health & Wellness Screening

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.

I acknowledge these services will be performed and collected today:

Signature – Informed Consent*

Digital Prescription Consent

In compliance with the FTC Contact Lens Rule, by signing this I am giving Perimeter West Eye Care permission to provide me with a digital copy of my prescription.

Signature – Digital Prescription Consent

Financial and Privacy Policy Consent

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.

Signature – Financial and Privacy Policy Consent

CAPTCHA