Clarion Optometry Group Registration Form

Name

First Last

Gender

Female
Male

Date of Birth

Social Security Number

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Responsible Party Name

First Last

Relation to Patient

Mother
Father
Other

Home Phone

Work Phone

Cell Phone

Okay to Text

Yes
No

Insurance Provider

Primary Insured Subscriber Name

Subscriber Date of Birth

Subscriber SSN

Married
Single
Other

Pharmacy you prefer to use

City

Who may we thank for referring you to our practice?

Family Doctor

How can we help you see better today?

Initial

Contact lenses require additional testing and evaluation, thus there is an additional fee for our contact lens patients. Our fee for these services ranges from $55 to $105. We will notify you of your exact fee before we provide this service. You have 6 weeks to finalize Contact lens prescription included in this fee.

Initial

ALL FEES INCLUDING INSURANCE COPAYS ARE DUE AT TIME OF SERVICE

Medication allergies?

Yes
No

If yes, please specify

The following pertains to your visual symptoms and health history. Please check all that apply.

Seizure Disorder

Yes
No

Height

Weight

# of hours spent daily on a computer

Initial

I understand that the benefits quoted to me are not a guarantee of payment and that I am responsible for all of my out of pocket expenses at the time of service. I understand that payment by my insurance company is based on my eligibility and coverage at the time services are rendered. I authorize payment by my insurance directly to Clarion Optometry Group Prof Corp.

Signature

The signed patient hereby authorized Clarion Optometry Group and associates to use or disclose the patient's PHI to carry out treatment, payment or health care operations on behalf of the patient. I understand the "Notice of Privacy Practices" HIPAA agreement and have been offered a copy of it.

Date

Your wellness vision exam includes a comprehensive assessment of the retina (the back of the eye). Please select the options you would like below.

Dilated Eye Exam: Eye drops will be instilled in your eyes to dilate your pupils. You may experience mild blurred vision and light sensitivity for about 3 hours. This gives our doctors the best view into your eye.
iWellness Scan Health Package digital imaging with OPTOS and OptoVue OCT scans of the macula: The iWellness Scan enables the doctor to provide a better level of eye health care. This technology allows the doctor to see beneath the surface of the back of the patient's eye. It provides cross sectional images of the layers of the retina which is not visible with traditional exam methods. This can help identify disease earlier when there may be no outward signs or symptoms and when the disease is most treatable.
Additional Charge: $38

Print Name

Signature