Primary Insured's Name + Date Of Birth
Secondary Insurance + ID Number (If Applicable)
Main Reason For Upcoming Exam*
Are you pregnant or nursing?
Past or current illnesses or injuries
Allergies/sensitivities to medications or other*
Do you smoke cigarettes?*
Do you use any illegal substances?*
Other medical conditions please specify below:
Have you ever worn contact lenses?*
If you currently wear contact lenses, what type/brand of lenses do you wear?
Other Comments to share with office staff or Doctor
HIPAA POLICY: I agree to allow my medical information to be shared with my insurance company for the sole purpose of billing and to any healthcare provider necessary for continuity of care. I acknowledge that I am awaare that Optometric ASsociates, PC has a notice of privacy practices available to me at all times during normal business hours. I fully understand that I am protected under HIPAA and will be required to sign a release for any and all medical records. I*
OFFICE POLICY: In order to control the cost of billing we require that the patient's portion of costs is due at the time of services rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardlness of insurance. All accounts with unpaid bills after 90 days are subject to collection fees. There will be a service charge on all returned checks. We require at least 24 hours notice for any cancellations or rescheduled appointments in order to be fair to our other patients. Any late cancellations or missed appointments are subject to a $50 fee. I acknoledge and accept the above policies*