Refer a Patient
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Map
Patient Forms
Welcome to Parmer Eye Care!
Date:
Patient's Name:
Last eye exam:
with Dr.
What is your main reason for coming in today?
Do you currently wear glasses?
Yes
No
Do you plan to update them?
Yes
No
Have you ever worn contacts?
Yes
No
Do you plan to update them?
Yes
No
If you currently wear contacts, how long have you worn them?
If you used to wear contacts, how long has it been since you stopped?
Are you happy with your glasses or contacts?
Yes
No
If not, why?
Are you interested in Laser Vision Correction?
Yes
No
List activities/hobbies that require special vision care:
Any special vision problems/conditions?
Do you or anyone in your family have any of the following conditions?
Condition
Which Family Member?
Dry eyes
Yes
No
Headaches
Yes
No
(Does Not apply to family)
Cataracts
Yes
No
Glaucoma
Yes
No
Retinal problems
Yes
No
Allergies/Sinus problems
Yes
No
(Does Not apply to family)
Diabetes
Yes
No
Thyroid problems
Yes
No
High Blood Pressure
Yes
No
Asthma/Lung disease
Yes
No
Cancer
Yes
No
HIV
Yes
No
(Does Not apply to family)
Pregnant
Yes
No
(Does not apply to family)
Other
Yes
No
Are you presently taking any medication?
Yes
No
Please list:
Personal Information
Patient Name:
Age:
Date of Birth:
Address:
City:
State:
Zip:
Home phone:
Work phone:
Mobile phone:
Spouse's Name
Email Address:
Social Security # (optional)
If child, parent's name
Name of Vision Insurance
Medical Insurance
Last eye exam:
Name of Dr.
Occupation:
Employer
Computer use:
How did you hear of our office?
If referral, who referred you?
If other, please tell us how you heard of us:
Method of Payment:
(if you have insurance, there may be a co-payment)
If other, please explain:
I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS OR OTHER INSURANCE BE MADE EITHER TO ME OR ON MY BEHALF TO PARMER EYE CARE FOR ANY SERVICES FURNISHED ME BY THAT OFFICE. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME, TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS, ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.
Parmer Eye Care
We want to provide the best professional advise, care and service possible. Our doctors and every member of our staff are dedicated to this goal. If you have any questions during any part of your vision examination today, feel free to ask. Please be aware of the following general office policies:
Payment and Insurance
All payment for services and materials should be made when they are provided or ordered. We accept cash, checks, credit and debit cards.
If you have any questions about your insurance coverage, we would be happy to help you. Sometimes, your vision insurance may have a co-payment. If you are unsure about what you will be responsible to pay, feel free to ask.
Glasses
Select your frames with care. We cannot change the frame once the prescription lenses are cut. We do warrant both frame and lenses for a period of 30 days after they are dispensed, and most of our frames and lenses have a manufacturer=s warranty of a year or longer.
We allow 30 days to adapt to your new prescription. It is not unusual to experience some difficulty adapting to a new prescription. Therefore we recommend wearing them exclusively for a while to get through the adaptation period. If, however you are unable to get used to your new glasses, you must let us know within 30 days. Any changes in the prescription that must be made for optical reasons in the first 30 days will be done at no charge. However, after 30 days, any changes whether optical or not, will only be done at full cost.
Contact Lenses>
Contact lenses are a medical device, the fitting of which must be overseen by a doctor. Unlike glasses, contacts fit directly on the surface of the eye and can adversely affect their health.
Our doctors are careful to make sure the lenses you receive fit your eyes properly and give you the best vision possible. Whether or not you have worn contacts before, in order for our doctors to be able to take responsibility for the fit of the lenses (i.e. give a prescription), they must be allowed to see how the lenses perform on your eyes. In order to do this, follow-up visits are necessary. Your prescription is not final until the doctor is satisfied that the contacts fit properly.
Once your contact lens prescription is finalized, it is good for a period of one year. You may request a copy of the prescription after it is finalized, but like a medication prescription, it will say how many contacts you may purchase with it. This will normally be the number of lenses you would need for a year’s supply. Even if you purchase your lenses here, you would need to bring the original prescription back so that we may note the number of lenses you have purchased with it.
If you would like to see how contacts feel on your eyes, we would be happy to put lenses on your eyes after your basic eye exam at no obligation to you. However, when you take the lenses out of the office, you will incur a fitting fee and become fully responsible for them. We allow you to wear the contact lenses on trial for thirty (30) days. However, if you lose, tear or otherwise make them unwearable, we must charge you for them (this does not apply to free trial disposable lenses). This is a risk you accept for the privilege of trying the lenses. If you return the lenses in good condition with in the 30 day period, the cost of the lenses is refunded. Doctor’s fees, of course, are not refundable. All follow-up visits within the 30-day trial period are included in your initial payment package. However, after 30 days, patients are charged office visit fees.
In order to maintain what we believe to be the best combination of quality and price in the eye care field, we must adhere to the above policies. We don’t believe you can find a better overall value in the optical profession that what we have to offer you at Parmer Eye Care.
Would you kindly sign below to indicate that you have read and understand the above policies?
If you choose to submit the form, you will be able to sign it in the office. Also, If you feel
uncomfortable
sending sensitive information over the internet, please use the "Just Print" button to print, and then you may bring the form into our office.
