Salem Vision Center New Patient Form

Date

Name

First Last

Nickname

Address

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

Social Security Number

Date of Birth

Email

Home Phone

Cell Phone

Work Phone

Occupation

Sex

Male
Female

Marital Status

Single
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Other

Are you here for

eyeglasses
contact lenses

Name of Primary Care Physician

Number

Last Physical Exam

Last Eye Exam

Medical Insurance Provider

Medical Insurance I.D. #

Medical Insurance Copay Dollar Amount

Vision Insurance Provider

Vision Insurance I.D. #

Medical Insurance Copay Dollar Amount

How did you find out about us?

If friend or relative, please indicate who

DIGITAL RETINAL SCREENING

Salem Vision Center, committed to providing the best patient care possible, offers high resolution digital retinal imaging. This new technology allows more detailed examination and documentation of the health of your eyes, and assists the doctor in early detection of many disorders, including cataracts, glaucoma, macular degeneration, retinal detachments, high blood pressure, and diabetes, before they can be otherwise detected. This procedure is as fast as taking a picture. IT DOES NOT REQUIRE DILATION DROPS, thus eliminating 30 minutes of exam time, and avoids blurry near-vision and light sensitivity. It is not covered by insurance for routine eye exams.

I DO want digital retinal imaging and agree to the charge of $42.00.
I DO NOT want the procedure performed.

Signature

Your signature above signifies that you authorize Dr. Michael J. Onyon and Associates, P.C. to bill your primary insurance carrier or vision plan for services rendered; you authorize the insurance company or vision plan to pay Dr. Michael J. Onyon and Associates, P.C. all benefits due; and you agree to assume responsibility for all charges not covered by the primary insurance company or vision plan. Correct insurance and vision plan information must be provided at the time services are rendered or orders are placed if you wish us to submit a claim to your plan or insurance company or apply benefits.