Patient Registration

Today's Date

Appointment Date and Time

Please select office location

Albany
Blakely
Camilla

Patient Name*

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Address*

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Home Phone

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Cell Phone

Email Address*

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Date of birth*

Age Today

Social Security #*

Male
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Preferred Language

English
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Parent's or Spouse's Name

Medical Insurance

Vision Insurance

Insured's Name

Insured's ID#

Insured's SSN

Insured's Date of Birth

Relationship to the insured

Please provide your insurance cards to the receptionist.

How will you settle your account today?

Check
Cash
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Race

Emergency Contact

Phone Number

Relationship

Name of Patient or Authorized Person

As a service, we will process your insurance claim. However, it is your responsibility to determine if this practice or your optometrist is participating with your insurance plan. We will not be responsible for penalties imposed on you by your plan, if we are not participants. Please note, that MOST medical insurance plans DO NOT cover routine eye health exams, eye glasses or contact lenses.

** I authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of benefits to be paid directly to Vision Source - Albany. I understand that I am financially responsible for charges not paid by insurance. I understand that any fees incurred for collection of an unpaid balance will be my responsibility. I acknowledge that all of the above information is correct.

First Last

Date

By checking here, you are verifying that the foregoing information is accurate and this will serve as your electronic signature.

Do you wear contact lenses?

Yes
No

Contact Lens Evaluation

Contact lens examinations include additional tests and procedures that are not performed in your routine eye exam. These additional tests and time spent with your doctor are necessary for a proper contact lens fitting and training. There is an additional fee for these services. If we find it is not covered by your insurance plan, you will be responsible for this charge.

Yes
No - but interested
No - not interested

Contact Lens Evaluation Fee STARTS at $80.

By checking here, you are signifying that you understand the Contact Lens Evaluation section.

Refraction Service and Fee

Refraction is the process of determining if there is a need for corrective eyeglasses or contact lenses. It is an essential part of eye examination and necessary to write a prescription for glasses or contact lenses. It is NOT a covered service by Medicare or most medical insurance plans. These plans consider refraction a "vision" service, not a "medical" service. Our office fee for refraction is $28.00 and is collected at the time of service in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will reimburse you accordingly.

Patient Acknowledgement

I have read the above information and understand that the refraction may be a non-covered service. I accept full financial responsibility for the cost of this service and understand it is due at the time of service. I understand that any co-payment, co-insurance or deductible I may have are separate from and not included in the refraction fee. I understand that my glasses or contact lens prescription will not be released until refraction fee is paid in full.

Name of Patient or Authorized Person

First Last

Date

Dilation (Optomap option only available at our Albany location)

At Vision Source, our doctors evaluate not only your vision, but also analyze the health of your eyes with detailed checks for diseases and disorders. We utilize both the Optomap retinal exam and pupil dilation to exam the internal health of the eyes.

Our doctors recommend either the Optomap or dilation at least annually. With these valuable procedures, we are providing you with the most thorough examination possible. Our doctors' assistants will discuss both the Optomap and dilation further with you today at your visit to determine which is right for you.

The Optomap Retinal Exam is a fast, easy and comfortable imaging technique that gives the doctors a view of the back of the eye (retina). We can also create a digital record of your retinal health that becomes part of your permanent electronic record. By comparing these images over time we can monitor and prepare for changes in your eye health.

Dilation involves the use dilation drops to temporarily increase the size of your pupils which allows the doctors to accurately investigate the health of your eyes and many important aspects of your general health. Dilation of your eyes is a temporary inconvenience; however, the benefits far outweigh the inconvenience. The inconvenience of eye dilation drops will diminish gradually. It will typically take several hours for the effects to wear off. During this time, reading ability may be more difficult and your sensitivity to light increases. For a short time, wearing sunglasses may be a necessary comfort.

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