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You And Eye Family Eye Care registration formReynaldo2020-12-29T21:32:55+00:00

You And Eye Family Eye Care registration form

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  • Welcome to our office

    It is our true pleasure to have you here today. We strive to offer patient-centered eye and vision care. Please complete the following to help us get to know you, and tailor your exam to your exact needs.

  • Patient Information

  • Patient Information

  • If you responded YES to any of the above 3 queries, we kindly ask that you reschedule your exam, for the safety of our patients, staff, and visitors.

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

  • *If you do not wish to receive text messages or email notifications please VERBALLY notify a staff member so we may modify your preferences.

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Drop files here or
  • Drop files here or
  • I, the undersigned may have insurance coverage and/or vision plan coverage with an insurance carrier(s)/ or surgical benefits, if any, otherwise payable to me for services rendered. I hereby request that Bhend Family Eye Care, PLLC dba You and Eye to file any claim(s) for medical and or/ preventative care benefits with my medical carrier prior to filing a claim(s) with any vision plan carrier or freestanding vision plan unless I indicate otherwise at time of service. I hereby authorize the release of all information necessary to secure the payment of benefits. As part of Dr. Bhend's annual recall program, I authorize Bhend Family Eye Care, PLLC dba You and Eye to utilize my name, mailing address, phone number, e-mail address and next appointment date and time to Bhend Family Eye Care, PLLC dba You and Eye for the purpose of providing annual reminder postcards, coupons and product information. I understand that I am financially responsible for all charges whether or not paid by insurance or vision plans; Co-pay, Co-insurance, and Deductibles are due at the time of service; Contact lens fitting fees, which are not generally covered by insurance nor a part of a routine eye exam, are due at the time of service; Bhend Family Eye Care, PLLC dba You and Eye charges $30.00 for any check returned from your bank; returned check fee(s) will be added to my unpaid balance and must be paid by credit card or in cash. Contact lens fitting fees are good for 90 days from date of original contact lens fitting; any contact lens fitting not completed within 90 days may incur additional fees.
  • Date Format: MM slash DD slash YYYY

  • Privacy Policy (HIPAA)

  • FOLLOW THIS LINK TO VIEW OUR NOTICE OF PRIVACY PRACTICES
  • Date Format: MM slash DD slash YYYY

  • Ocular History

  • Optomap Retinal Screening Photography

    While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough screening of the retina is critical to verify that your eye is healthy. This can lead to early detection of common diseases, such as glaucoma, diabetes, macular degeneration, and even cancer. The photos are quick, painless, and may not require dilation drops. More than 80% of your retina can be evaluated in one single image while traditional imaging methods typically only show 15% of your retina at one time. These photos will become a part of your medical records and will allow the doctor to compare them with subsequent photos at future exams in order to detect even the smallest amounts of change. Dilation is the only way 100% of your retina can be seen and can also help reduce the effects of your/your child's focusing which allows for a more accurate prescription.

  • Medical History

  • Review of Systems

  • Please note any immediate family history (parents, siblings, children) for the following conditions:

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