Nature of Visit
I plan to order new glasses today.
My driving sunglasses have my current prescription
I have a separate set of computer glasses.
I am considering LASIK (laser eye surgery).
I wear or want to wear contact lenses.
I was told I cannot wear contacts.
I plan to order contacts today
I need an itemized receipt for my Flex Spending Account
High Blood Pressure
Other health condition:
Date of Last Eye Exam:
Last Eye Doctor/Location:
How did you find our office?
Name of Physician/Pediatrician:
Name of Specialist(s):
By signing below, I acknowledge that a copy of Claremore Eye Associates Notice of Privacy Practices has been made available to me. I hereby authorize any necessary medical treatment by the optometrists in the practice of Claremore Eye Associates, and agree to be financially responsible for my bill for materials and/or services rendered. I authorize this oce to release any information necessary to expedite insurance claims. I further authorize Claremore Eye Associates to release or obtain any required medical information from my attending physicians or any medical facility as necessary for my care and to decide which insurance plan should be billed for my services. I also authorize my insurance provider to make payments on my behalf to Claremore Eye Associates. Payments for services rendered are non-refundable. Your medical records will be electronically archived indefinitely, and all discarded documents are shredded to protect personal information. Our oce may use standard email to communicate with you for the purpose of sending payment receipts or copies of your glasses/contact prescriptions.
Please inform our Patient Services Coordinator if you have more than three medical insurance policies and need an additional sheet to supply the requested information.
Dr. Smith. Dr. Stover, and Dr. Crissup want ALL patients to have a digital image of the retina annually. The fee is only $35 (it is usually not covered by insurance). There is no charge for self-pay eye exams.
Retinal and optic nerve problems such as macular degeneration, glaucoma, diabetic retinopathy, and melanoma are easily documented, often without pupil dilation.Early detection of eye disease is crucial!
***The flash during imaging is not recommended for patients with a history of epilectic seizures triggered by flashing lights. Please notify our staff if you have a history of such seizures.***
One fine body…