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Walden Eye Care and Family Centeradmin2017-07-06T01:14:30+00:00

Walden Eye Care and Family Eye Center

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • If using insurance to pay for any part of this visit please specify below:

  • Dilation

    Dilation of the pupils allows the doctor to obtain a more thorough view of the retina. Therefore, it is highly recommended that the pupils be dilated. The procedure entails using eye drops that will increase your pupil size. The most common side effects include sensitivity to light, decreased near vision and glare. It will take anywhere from 15-30 minutes for your pupils to dilate and side effects will last anywhere from 2-4 hours. If you choose to be dilated, it may help to wear your sunglasses after leaving the office. Any retinal problems that are not found should you choose not to be dilated, will not be the doctor's responsibility. The doctor will be happy to discuss dilation with you during your exam.

  • Authorization and Release

    Your insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for the services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them not with our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid by your insurance. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked in writing. A photocopy of this assignment is considered to be valid as the original. By signing this statement, you agree to be financially responsible for all charges.

  • Personal Medical History: Please check ALL conditions for which you are being treated, or take medications for.

  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • E.g. Mother, Father, Brother, Sister, Son, Daughter
  • Include the Dose, and All vitamins and Supplements.
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