EYE TO EYECARE

Registration Form

PATIENT INFORMATION

How Did You Hear About Us?

VISION AND MEDICAL INSURANCE INFORMATION

OCULAR HEALTH

OCULAR AND MEDICAL HISTORY

FAMILY OCULAR AND MEDICAL HISTORY

MEDICATIONS AND ALLERGIES

EYE TO EYECARE OFFICE POLICY

Financial Policy

All co-pays and payments are due at the time of service. Fees paid for eye examination, contact lens evaluation, medical services, purchase of glasses and/or contact lenses are to be made in FULL on the day of purchase and are non-refundable.

Appointments

Please help us better serve you and other patients by keeping your scheduled appointments. We require you to call, email, or message the office at least 24 hours prior to your appointment time if you need to cancel or reschedule your appointment. Any patient that comes to their appointment more than 10 minutes late, will be considered a "No-Show" and may need to be rescheduled. At the Office's discretion, "No-Shows" to scheduled appointments or repeated rescheduling may result in a "Walk-In Only" status on the patient’s account and a $25 no-show fee may be assessed. Please see our "Appointments and Cancellations Policy" for more information.

Glasses

All orders for glasses are FINAL. After your exam, you can return to the office within 60 days at no charge for a re-check with the doctor if you are experiencing any problems such as blurred vision, headaches, or any other discomfort. After 60 days, there is a $50 fee.

Manufacturer Warranty on Glasses and/or Lenses

Frames and Premium lenses that have a manufacturer's warranty can be replaced one time within one year of purchase upon approval from the manufacturer for defects. A handling fee of $25 for will apply per frame or pair of lenses replaced. Some restrictions apply.

Contact Lenses

All orders for contact lenses are FINAL. All contact lens follow-up visits or finalization of contact lens prescriptions must be done within 30 days of the Contact Lens Exam, unless otherwise instructed by the doctor. After 30 days, there is a $30 fee.

HIPAA Privacy Acknowledgement of Notice of Privacy Practices

I understand, acknowledge, and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records if I desire on the date identified below.

The following person (s) may have access to information in my records:

Appointments and Cancellations Policy

Thank you for trusting us with your Eyecare. When you schedule an appointment, we set aside time specifically for us to provide you with the highest quality of care. Should you need to cancel or reschedule an appointment, please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This allows us to schedule other patients who may be waiting for an appointment.

Please carefully review our Appointment Cancellations and No-Show policy below.

We, at Eye to Eyecare, understand that sometimes you may need to cancel or reschedule your appointment. However, please understand that when a patient does not show up for their scheduled appointment, it creates an unused appointment slot that could have been used to allow care for another patient. To be fair to all of our patients, we here at Eye to Eyecare have instituted the following policy:

• Please contact the office to cancel your appointment at least 24 hours in advance. This will allow us to accommodate other patients who are seeking an appointment.
• If you do not cancel your appointment 24 hours in advance and do not present to the office for your appointment, this will be documented as a “No-Show” appointment and you will be charged a $25 No-Show Fee per incident. Please note, the cancellation fee amount is at the discretion of the office.
• Repeated rescheduling, in some cases even within the 24 hours period, may result in a “Walk-In Only” status on the patient’s account, and the $25 No-Show fee may be assessed.