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Patient Form

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Patient Information

Name *
Address *
Date Of Birth *
Sex *
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Marital Status
Employed
Student

Receipt of Privacy Policies

I acknowledge that I have been offered or upon request I can obtain a copy of the Notice of Privacy Practices for this office. *

Acknowledgment of Professional Contact Lens Service

In addition to the exam cost, there could be an additional design, fit, and follow-up charge that covers training and up to two additional visits with the doctor. For exact pricing, please speak to one of our staff members. *

Consent for Disclosure

I authorize Thomas Eye Center to disclose information to the individual(s) listed below by discussion: in my presence and also when I am not physically present; including disclosure by telephone, fax, email or mail any information related to my medical care, account information, making of appointments, prescription concerns, etc. I understand that this consent is in effect until revoked by me with written notice to the practice.

Patient Financial Responsibility Policy

  • Payment is required at the time that services are rendered. This includes coinsurances, copayments, and deductibles for participating insurance companies. Thomas Eye Center accepts cash, personal checks (in state only), Visa, MasterCard, Discover, American Express, and Care Credit. There is a $30.00 service charge for each returned check.

  • Thomas Eye Center doctors perform a comprehensive eye examination that checks for all eye diseases, structures of the eye and includes for “routine vision” as all exams performed are medical in nature.

  • A charge of $50.00 will be incurred for appointments missed or cancelled without a 24-hour notice. Excessive abuse of missed appointments may result in discharge from the practice.

  • Payment in full is required for all materials (glasses and contact lenses) before they are ordered. Once payment on materials is made, your order is immediately placed and the manufacturing of your eyeglass lenses begins. Being that eyeglass lenses are created specifically for your eyes there are no returns or refunds on your eyeglass lenses once they have been ordered.

    • I, the undersigned, have read and understood this information authorize the release of medical and other necessary information to my insurance company to process claims for services rendered. I hereby authorize my insurance company to distribute payment of my coverage directly to Thomas Eye Center. I understand that I am responsible for all charges regardless of my insurance benefits. I authorize the use of this signature on insurance submissions. I certify that I am the patient or parent/guardian authorized to furnish the information requested.
    Date *
    Patient Name *
    Name of Parent or Guardian (If patient is under 18)

    Patient Medical & Eye History

    Do you currently experience any of the following?
    Do you currently wear contacts?
    Have you ever been diagnosed or treated for the following?
    Have you ever been diagnosed or treated for the following?

    Family Medical & Eye History

    Is there a family medical history of any of the following?

    Amblyopia/Lazy Eye
    Glaucoma
    Blindness
    High Blood Pressure
    Retinal Problems
    Macular Degeneration
    Diabetes