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Maine Optometry – GorhamBerenice2024-02-20T16:42:32+00:00

Maine Optometry - Gorham

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Patient Registration

PATIENT:*
Address
MM slash DD slash YYYY
STUDENTS:
IF UNDER 18:

YOUR OCULAR HISTORY – Past & Present

Do you wear eyeglasses?
If yes,
Do you wear contact lenses?
If yes,
Have you worn contacts in the past?
If yes,
PLEASE CHECK ALL THAT APPLY:
Blurred Vision:
History of a Turning Eye:
Contacts:
Surgery to Straighten an Eye:
Cataract Surgery?
Patching an Eye:
Please list any additional information about your eyes:

PLEASE CHECK ALL THAT APPLY TO YOUR PERSONAL HEALTH

CARDIOVASCULAR:
IMMUNOLOGIC:
CONSTITUTIONAL:
INTEGUMENTARY:
EAR, NOSE & THROAT:
MUSCULOSKETAL:
ENDOCRINE:
NEUROLOGICAL:
Diabetes:
GASTROINTESTINAL:
PSYCHIATRIC:
GENITOURINARY:
RESPIRATORY:
Do You Smoke?
HEMATOLOGY/ ONCOLOGY:
FAMILY HISTORY
MEDICATIONS:
ALLERGIES:
MM slash DD slash YYYY

Contact Lens Prescription Signed Acknowledgment Form

Included below is important information to review prior to receiving your contact lens prescription.


The Centers for Disease Control and Prevention (CDC) makes clear, "Contact lenses can provide many benefits, but they are not risk-free— especially if contact lens wearers don't practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment." 

The CDC recommends the following for contact lens wearers:

  • Schedule a visit with your eye doctor at least once a year.
  • Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision.
  • Understand that eye infections that go untreated can lead to eye damage or even blindness.?
     

The Food and Drug Administration (FDA) indicates:

  • "To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It's safer to be re-checked by your eye care professional. "


Symptoms of Eye Infection include:

  • Irritated, red eyes
  • Worsening pain in or around the eyes-even after contact lens removal
  • Light sensitivity
  • Sudden blurry vision
  • Unusually watery eyes or discharges

Sign below to acknowledge that you were provided with a copy of your contact lens prescription at the completion of your contact lens fitting.

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.

PEACE OF MIND PROTECTION PLAN

This protection plan covers eyewear in the event of accidental damage. The cost of the plan is $29.99. When utilized, there is a $25.00 copay for Frame replacement, a $25.00 copay for Lens replacement, and a $50 copay if replacing both. Children 12 and under will automatically have the plan added at no cost, however, copays will apply when utilized. The exchange period will be extended to 90 days (1 time only) when coverage is purchased. Copays will not apply for the 1-time exchange; however, any additional frame cost is the patient’s responsibility. The plan does not cover lost or stolen glasses; we must have the damaged eyewear back. The plan is limited to 5 redemptions in one year from the date of pick up.

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:

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.

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.

Self-Pay: Patients with no insurance coverage are expected to pay, in full, at the time of service.

Optomap® Retinal Imaging Fee: As a part of our standard of care beginning in 2023, we perform the Optomap® Retinal Imaging during all routine eye examinations. These scans provide an in-depth view of the retina and allow us to do a side- by-side comparison year over year. This information is crucial for us to monitor your eye health. Insurance typically doesn't cover the cost of advanced screenings, and a fee of $20.00 is due at the time of service. If the doctor determines a medical finding, the cost of these images will be billed to your medical insurance. Maine Optometry will provide this service free of charge for patients who are 8 years and under.

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, final cost of eyewear/lens may have a small balance due or credits due to variations of 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 patients account that are incurred will not be subject to 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 scheduling or dismissing 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
MM slash DD slash YYYY
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