2020 Eyewear
Patient Entry Form
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Email *
Last Name *
First Name *
Middle Initial *
Birth Date *
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Age *
Address *
City *
Zip Code *
Telephone Home *
Cell Phone *
Social Security Number (optional)
Occupation *
Employer *
Insurance Information
Do you have vision insurance? *
If Yes List Carrier
Policy holder if other than patient
Last Name
First Name
Relation to patient
Birth Date
MM
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DD
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Primary phone number
Social security number
Patient history
How long since last eye exam? *
What is primary reason for exam today? *
Do you or any blood relatives have diabetes? *
Are currently taking any medications? *
Are you allergic to any medications? *
Do you have high blood pressure? *
Ocular History
Have you ever had any eye disease, injury or surgery? *
Do you ever see double? *
Do you have frequent headaches? *
Do you or any blood relatives have cataracts? *
Do you or any blood relatives have glaucoma? *
Do you or any blood relatives have macular degeneration? *
Contact Lens Information
Are you interested in wearing contact lenses? *
Are you a new wearer of contact lenses? *
If yes what brand?
Do you have comfort issues?
Clear selection
Current RX for contact lenses?
Dryness issues?
Clear selection
Insurance Authorization and HIPAA
Financial Policy
Full payment is due when services are rendered. Insurance must be presented and member eligibility obtained on date of service for insurance to be filed. We accept cash, Visa, Mastercard, Discover, American Express  and checks. Refunds will not be issued on services.Eyeglasses and contact lens prescriptions are valid one year from exam date.
Insurance claims
Initial Each item below.
20/2 Eyewear , inc is a participating office with certain insurances which means 20/20 eyewear Inc. agrees to abide by the terms of those contracts only. *
Required
I understand and agree that regardless of my insurance status I am ultimately responsible for the balance on my account for all services rendered. I understand that ROUTINE eye examinations may not be considered necessary by insurance plans and I agree to be responsible for payment of such services. *
Required
I hereby authorize 20/20 Eyewear Inc. to furnish information to the insurance carriers concerning my illness, if any, treatments and assign the doctor(s) all payments for medical services rendered myself or dependents. I request that payment or any insurance benefits to  be made to me on behalf of 20/20 Eyewear, Inc. for any services furnished to me by the doctor. I authorize any holder of medical information about me to be released to the Health Care Financing Administration or it's agents any information needed to determine these benefits payable for relatable services. *
Required
Acknowledgment of Receipt of Notice of Privacy Practices
The notices of privacy practices you have been given describes the uses and disclosures of your health information in detail. I acknowledge that I received the Notice of Privacy Practices from this office  and 20/20 Eyewear, Inc. *
Required
Contact lens patients
Refunds will not be issues on services rendered. A contact lens evaluation does not guarantee that any patient will be able to wear contact lens successfully. If patients are new wearers of contacts, and insertion and removal training class must successfully completed in order to have the contact lenses dispensed.  
****Your eyes may be dilated after exam and you may need a ride home***
I have read and understand

By filling in your name you are agreeing to our service agreement and stating that all the information you entered is true.
Full name *
Date *
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