Patient Forms Appointment Request for New and Existing Patient Please fill out after calling and making an appointment NEW PATIENT FORM Name* First Last Email* Address* Phone Number*Birth Date** MM slash DD slash YYYY Age*Emergency Contact Name* First Last Phone Number*Acknowledgment of Receipt of Privacy Notice By signing this acknowledgment of Receipt of Notice of Privacy Practices (the “Notice”): I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that the Location may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the Location to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by the Location (for example, mailings of exam reminders or Information about services/products provided by the Location). | can be assured that this Location does not sell my personal health information of any kind to a third party for such party’s own use. I acknowledge and agree that the Location may submit my vision benefit claims to my plan sponsor or health plan to receive reimbursement directly for the vision services and products that I have received from the Location. Patient Signature or Patient's Legal RepresentativeDate* MM slash DD slash YYYY Signature above is only acknowledgment that I have seen and read this policy. Date* MM slash DD slash YYYY For those with vision insurance: I understand that verification of coverage & authorizations must be obtained prior to eye exam. Patient signatureNOTE: We are providers for Eyemed vision plans. Please present your Eyemed Card (or Aetna discount plan #) and valid picture ID at the front desk. Eyemed plan name Policy # Patient’s Social Security# Patient’s Birthdate* MM slash DD slash YYYY Responsiblemember: Name Birthdate* MM slash DD slash YYYY Employer Relationship to patient: Medical information release: I request that payment of authorized insurance be made either to me or on my behalf to Dr. Sheila Merritt for any services furnished me by that doctor. I authorize any holder of medical information about me to release to the health care administration and its agents any information needed to determine these benefits or the benefits payable for related services. Patient signature XDate* MM slash DD slash YYYY Dilation: Although we can determine a spectacle prescription without a dilated retinal exam, this only provides a limited view of the inside of your eye and some very serious conditions may go undetected including, but not limited to, retinal holes, tears, and detachments. Drops are placed in the eyes to enlarge the pupils. This dilation usually lasts for 2-6 hours. During this time, your eyes will be sensitive to light and your vision may be blurry, especially at near. This procedure is included in your comprehensive eye exam. I can have this procedure today. I am unable to do this procedure today and need to reschedule it. Eye HistoryReason for today's visit*Eye ExamComprehensive Eye ExamContact Lens FittingVision IssuesEye problems related to health concernsDate of last exam MM slash DD slash YYYY Any special eye or vision problems* List any previous eye injuries Does your work require special vision care? ExplainHow did you hear about us? EXISTING PATIENT FORM Name* First Last Email* Address* Phone Number*Reason for today's visit?*Eye ExamComprehensive Eye ExamContact Lens FittingVision IssuesEye problems related to health concernsDo you desire a contact lens exam today?* Yes No Acknowledgment of Receipt of Privacy Notice By signing this acknowledgment of Receipt of Notice of Privacy Practices (the “Notice”): I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that the Location may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the Location to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by the Location (for example, mailings of exam reminders or Information about services/products provided by the Location). | can be assured that this Location does not sell my personal health information of any kind to a third party for such party’s own use. I acknowledge and agree that the Location may submit my vision benefit claims to my plan sponsor or health plan to receive reimbursement directly for the vision services and products that I have received from the Location. Patient Signature or Patient's Legal RepresentativeDate* MM slash DD slash YYYY Signature above is only acknowledgment that I have seen and read this policy. For those with vision insurance: I understand that verification of coverage & authorizations must be obtained prior to eye exam.Patient signatureDate* MM slash DD slash YYYY Note: We are providers for Eyemed vision plans. Please present your Eyemed Card (or Aetna discount plan #) and valid picture ID at the front desk. Eyemed plan name Policy# Patient's Social Security# Patient's Birthdate* MM slash DD slash YYYY Responsible member: Name Birthdate* MM slash DD slash YYYY Employer Relationship to patient Medical information release: I request that payment of authorized insurance be made either to me or on my behalf to Dr. Sheila Merritt for any services furnished me by that doctor. I authorize any holder of medical information about me to release to the health care administration and its agents any information needed to determine these benefits or the benefits payable for related services. Patient signature XDate* MM slash DD slash YYYY Dilation: Although we can determine a spectacle prescription without a dilated retinal exam, this only provides a limited view of the inside of your eye and some very serious conditions may go undetected including, but not limited to the health retinal holes, tears, and detachments. Drops are placed in the eyes to enlarge the pupils. This dilation usually lasts for 2-6 hours. During this time, your eyes will be sensitive to light and your vision may be blurry, especially at near. This procedure is included in your comprehensive eye exam. I can have this procedure today. I am unable to do this procedure today and need to reschedule it.