Skip to content
Search for:
Maine Optometry – Brunswick
Berenice
2022-12-06T14:05:47+00:00
Maine Optometry - Brunswick
Step
1
of
3
33%
Patient Registration
PATIENT:
*
First
M.I.
Last
Address
Street Address
City
State
Zip
Home Phone
Home Phone
Cell Phone
E-mail
Birth Date
MM slash DD slash YYYY
Age
Social Security #:
OCCUPATION:
Employer
OCCUPATION:
Employer
Name of previous eye doctor
Approximate date of last visit
Primary Care Physician
Insurance
STUDENTS:
School
Teacher
Grade
IF UNDER 18:
Father’s name
Mother’s name
YOUR OCULAR HISTORY – Past & Present
Do you wear eyeglasses?
No
Yes:
If yes,
Distance
Near
For what?
Do you wear contact lenses?
No
Yes:
If yes,
Soft
Hard (gas permeable)
Brand:
Have you worn contacts in the past?
No
Yes:
If yes,
Soft
Hard (gas permeable)
How long ago?
PLEASE CHECK ALL THAT APPLY:
Watery Eyes
Eyestrain
Frequent Loss of Place While Reading
Optic Neuritis
Shimmering / Geometric Lights
Black Outs / Vision Loss
Itchy Eyes
Eye Pain
Poor Reading Comprehension
Iritis / Uveitis
Flashing Lights
Dry Eyes
Double Vision
Fluctuating Vision
Floating Spots
Reduced Color Vision
Blurred Vision:
Distance
Near
Right
Left
History of a Turning Eye:
Right
Left
Surgery to Straighten an Eye:
Right
Left
Patching an Eye:
Right
Left
Cataract Surgery?
Right
Left
Cataracts:
No
Yes
Glaucoma:
Macular Degeneration:
Eye Injury:
How long?
How long?
What?
Please list any additional information about your eyes:
Notice of Privacy Practice
I acknowledge that I was offered a copy of MAINE OPTOMETRY P.A. Notice of Privacy Practices
Signature:
Date:
MM slash DD slash YYYY
PLEASE COMPLETE THE REST OF THIS FORM SO WE CAN BETTER SERVE YOUR EYE CARE & EYEWEAR NEEDS
PLEASE CHECK ALL THAT APPLY TO YOUR PERSONAL HEALTH
CARDIOVASCULAR:
Chest Pain
Heart Disease
High Blood Pressure
High Cholesterol
Irregular Heartbeat
Pacemaker
Other
If other, what?
ADDITIONAL INFORMATION:
CONSTITUTIONAL:
Chronic Fatigue
Frequent Dizziness
Other
If other, what?
ADDITIONAL INFORMATION:
EAR, NOSE & THROAT:
Chronic Sinus Infection
Chronic Ear Infection
Hearing Loss
Other
If other, what?
ADDITIONAL INFORMATION:
ENDOCRINE:
Diabetes Type I
Diabetes Type II
Thyroid Disorder
Other
How long?
Average blood sugar:
Fasting:
HbA1c reading:
If other, what?
GASTROINTESTINAL:
Crohn’s Disease
Irritable Bowel
Other
If other, what?
ADDITIONAL INFORMATION:
GENITOURINARY:
Kidney Disorder
Menopausal
Pregnant
Prostate Disorder
Other
If other, what?
ADDITIONAL INFORMATION:
HEMATOLOGY/ ONCOLOGY:
Cancer
No
Type:
Approximate date of diagnosis:
ADDITIONAL INFORMATION:
IMMUNOLOGIC:
Lupus
Multiple Sclerosis
Sarcoidosis
Other
If other, what?
ADDITIONAL INFORMATION:
INTEGUMENTARY:
Eczema
Rosacea
Other
If other, what?
ADDITIONAL INFORMATION:
MUSCULOSKETAL:
Fibromyalgia
Muscular Dystrophy
Rheumatoid Arthritis
Trauma/Injury
Other
What/When?
If other, what?
ADDITIONAL INFORMATION:
NEUROLOGICAL:
Headaches
Migraines
Numbness/Tingling
Stroke
Other
If other, what?
ADDITIONAL INFORMATION:
PSYCHIATRIC:
Anxiety
Dementia
Depression
Other
If other, what?
ADDITIONAL INFORMATION:
RESPIRATORY:
Asthma
Emphysema
Persistent Cough
Shortness of Breath
Tuberculosis
Other
If other, what?
ADDITIONAL INFORMATION:
Do You Smoke?
Yes
No
If yes, for how long?
FAMILY HISTORY
Blindness
Cataracts
Color Vision Problems
Glaucoma
Macular Degeneration
Misaligned Eyes
Retinal Tear/Hole/Detach
Who was diagnosed?
MEDICATIONS:
ALLERGIES:
Signature:
Date:
MM slash DD slash YYYY
Patient Privacy Form
I agree to the privacy policy.
By signing below, I give Maine Optometry, P.A. my permission as the Patient/Legal Guardian/ POA to release my Personal Health Information (PHI) in accordance with established H.I.P.A.A laws for the following:
To release any information regarding my diagnosis and care to my primary care physician (PCP) and any other physicians involved in managing my conditions
To act on my behalf regarding any and all contact with my insurance carrier(s) and also to release any information regarding my diagnosis and care with the primary insurance carrier and any other supplemental insurance carriers
To bill my Insurance company for any services which I have received and understand that regardless of my Insurance status, I am ultimately responsible for any balance on my account. It is also my responsibility to obtain any necessary referrals in a timely manner (3-5 days) from my PCP. If Maine Optometry, P.A. does not receive my referral, I will be responsible for the full payment of services provided. I further understand that any payment due that is delinquent past 30 days is subject to a $15.00 per month billing charge.
By signing I am also aware that any balance due over 90 days may be reported to the Maine Credit Bureau Reporting Service. And that I've been informed that I will be notified by Maine Optometry, P.A. prior to reporting my delinquent account and that the delinquency will stay on my financial record for 7 years.
I also understand that any diagnosis found to be medical in nature during any examination/follow up that it will be sent to my medical insurance provider and that if during my routine preventative eye exam any medical diagnosis (i.e. Cataract, Dry Eye Syndrome, Allergies, Glaucoma etc.) are found, that my routine exam may be considered medical and will be sent to my medical insurance provider for coverage regardless or any vision specific coverage.
Patient Name (Please Print)
First
Last
Patient/Legal Guardian/POA (Please Sign)
Date:
MM slash DD slash YYYY
SATISFACTION GUARANTEE
The Optometrists and staff at Maine Optometry want you to be completely satisfied with every aspect of your visit with us. If you are not, please notify any team member within 14 days of receiving your exam, eyewear, or contacts and we will do what it takes to make it right. Please see the time limits below.
LENS OR FRAME CHANGES
Your complete satisfaction is our goal! After evaluation by an optician, we will work with you to determine what solution will best meet your needs and resolve any issues. We allow a 60-day period from the date of purchase for remaking lenses or changing frames under this policy. Any difference in price will be charged for upgrades. We cannot refund when changing to lower priced lenses, frames, or options, but will provide the remake at no charge. We feel that a patient will know within 60 days if they are satisfied with their glasses. However, we will always work with our patients to deliver the best quality and service at a fair price. Generally, we do not encourage refunds, as we will do everything possible to ensure your satisfaction. Our labs cannot cancel orders once in process. Cancellations will result in a 20% service fee.
EYEWEAR WARRANTY
All frames and lenses purchased from Maine Optometry are covered against manufacturer defects within one year from date of purchase. Replacements under warranty are covered during the one-year time period from date of original purchase and warranty does not start over at time of replacement. Lenses have a one-time warranty replacement for scratches within one year from date of purchase. Maine Optometry offers complimentary cleaning, adjustments, replacement nose pads, and minor repairs any time, at any of our locations, for the life of your eyewear.
CONTACT LENS RETURN POLICY
With regard to sales of non-specialty soft contact lenses, any unopened & unmarked boxes may be returned for a full refund, or exchanged, within 60 days. All sales of specialty gas permeable (rigid) and hybrid (containing both rigid and soft components) contact lenses are final. If, however, there are discrepancies between the doctor’s initial prescription and final prescription, any changes for the actual prescription will be honored at no charge as long as enough time is given for the lenses to be exchanged to be mailed and received by manufacturer within 60 days from time of order. All contact lenses that need to be ordered will need to be paid in full before they are ordered.
PROFESSIONAL FEES
Within 60 days from the date of original exam, a complimentary Rx check will be performed if needed. From 60-120 days, the refraction fee will be discounted 50% for this service. After 120 days, the full refraction fee will be charged for Rx checks.
Personal Health Information and H.I.P.A.A
By signing below, I give Maine Optometry, P.A. my permission as the Patient/Legal Guardian/POA to release my Personal Health Information (PHI) in accordance with established H.I.P.A.A laws for the following:
TTo release any information regarding my diagnosis and care to my primary care physician (PCP) and any other physicians involved in managing my conditions.
To act on my behalf regarding any and all contact with my insurance carrier(s) and also to release any information regarding my diagnosis and care with the primary insurance carrier and any other supplemental insurance carriers.
I acknowledge that I have read and understand all aspects of the policies explained above.
Patient Financial Responsibility and Cancellation Policy
Co-Payments:
Your co-payment is due at time of service and will be collected at check-in.
Self-Pay:
Patients with no insurance coverage are expected to pay, in full, at the time of service.
Optomap® Retinal Exam:
As part of your routine eye examination, we will take a computerized ultra-wide field digital scan of your retina. These scans provide an in-depth view of the retina and allow us to do a side-by-side comparison year over year; it is important information for us to monitor your eye health. Insurance typically does not cover the cost of advanced screenings and we will perform the Optomap® Retinal Exam for $20 as a part of our standard of care.
Outstanding Balances:
Payment is due upon receipt of statement. Balances not paid within 90 days of the initial billing may be subject to a $15 per month late fee. In the event the account is past due after 90 days, the account may be sent to a collection agency.
Eyewear/Lens/Contacts Lens:
Purchases must be paid in full at the time of order. We will gladly hold your order with a 50% deposit and the order will be placed upon receipt of full payment. Upon pickup, the final cost of eyewear/lens may have a small balance due or credits due to variations in the insurance company’s final rates.
Returned Checks:
Checks returned for insufficient funds (NSF) will incur a $25.00 charge and we will automatically redeposit the check. If the check is returned a second time, another $25.00 service charge, plus the face value of the check will be charged back to the patient’s account and will be due immediately in an alternate form of payment.
Account Credits:
Any credits on a patient’s account that are incurred will not be subject to an automatic refund of $40 or below.
Medical Diagnosis:
Please be advised that most insurance companies do not consider treatment for a medical diagnosis by an optometrist to be a Routine Eye Exam. These services will be billed to your medical insurance carrier and subject to their terms and conditions.
Cancellation and No-Show Policy:
Patients are requested to cancel or reschedule their appointments at least 24 hours in advance to allow the practice enough time to reschedule the time slot. However, we understand that this may not always be possible and allow for one cancellation under 24 hours or one no-show within a 24-month period. The practice retains the right to refuse to schedule or dismiss patients from the practice that have incurred three or more violations of the policy within a 24- month period. New patients or patients that have not been seen in the previous 36 months that have two or more violations will be dismissed for failure to establish as a patient.
I hereby acknowledge that I have read and understand the above information.
Patient Name
First
Last
Date
MM slash DD slash YYYY
Guardian
Relationship to Patient
Go to Top
