Beggs Family Vision

  • Beggs Family Vision, Phillip J. Beggs, Independent Doctor of Optometry

    Wellness Vision Exam (Please DO NOT fill out this form if you have ANY of the following: diabetes, cataracts, glaucoma, flashes of light, retinal disease, red eye, or eye pain. Ask the assistant for the medical form.)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
    Please check one.
  • Insurance patients only: (Prior authorization required)

  • Assignment of Benefits:

    I hereby instruct and direct the insurance company named above to pay the provider, Philip J. Beggs, O.D., for the professional and or medical expense benefits allowable toward the total charge(s) for the professional charge(s) rendered. This is a direct assignment of my benefits under this policy. I have agreed to pay, in a current manner, any balance of said professional charge(s) over and above this insurance payment.
  • Date Format: MM slash DD slash YYYY
  • Contact lens patients only: Within two month of date of exam, follow-ups related to the fitting of the contacts are at no charge. Visits related to eye infections are excluded. All follow-ups after the two month period will be charged $30 per visit.

  • Initial
  • Medical History (Mark “S” for Self and “F” for Family)

    If yes, notify the doctor.
  • Pupil Dilation

    Dilation is recommended for evaluating the health of the eye. Dilation will cause sensitivity to light and near blur for 3-6 hours. There is no additional charge for this service. Please initial next to Yes or No. If you do not initial, the optometrist will decide for you.
  • Initial
  • Initial
  • HIPAA Privacy Notice

    I have reviewed the HIPPA policy and understand that my medical records will not be released without my written consent.