Patient Information

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Patient Information
May we contact you by text?  If yes, what number? *

Insurance Information

Please note that most insurance does NOT cover the Contact Lens Evaluation/Follow-up.
If you are not the primary on your insurance, please list the following information:

Lifestyle Questions

Have you been diagnosed or treated for any of the following?

Patient Medical History

Are you currently experiencing any of the following health problems?

Family Medical / History

If there is a family history of any of the following, please list their relationship to you. (Father, Mother, Sibling, etc.)
Corneal Problems
Heart Disease
Lazy Eye
Retina Problems
Macular Degeneration

Consent to Treat

By signing this form, I consent to treatment for myself and/or on behalf of the minor or dependent for which this information pertains.  I give my permission for the doctor to examine, diagnorse, and initiate treatement as deemed appropriate.  I further attest that I am the parent or legal guardian fo the minor or dependent and have the authority to authorize care or treatment.
By signing this form, I consent to treatment for myself and/or on behalf of the minor or dependent for which this information pertains.  I give my permission for the doctor to examine, diagnorse, and initiate treatement as deemed appropriate.  I further attest that I am the parent or legal guardian fo the minor or dependent and have the authority to authorize care or treatment.
While Premier Eyecare is happy to file  my insurance for me, I understand I am responsible for all copays and charges not covered or denied by my insurance.

Please Read and Sign if Interested in Contact Lenses

Contact Lens Prescriptions Expire Yearly

Professional Standards of Care require that all people who wear contact lenses have a full comprehensive exam and contact lens evaluation at least once every year.  We will not dispense contact lenses or write a contact lens prescription without a yearly comprehensive eye exam and contact lens evaluation, including all necessary follow-up visits.

Additional Professional Fees Apply Towards Contact Lens Evaluations

This fee is dependent on the level of complexity of the fitting process which is determined by the doctor evaluating your vision requirements, the type of contact lenses needed and the health of your eyes.

Follow-up Visits for Contact Lenses

Ongoing follow-up visits as needed are included in the professional fee for up to 90 days.  It is the patient's responsibility to communicate with our office if any changes are desired within the fitting time frame.  Additional visits outside of the initial 90 days will be charged $55 per visit.

The evaluation fees do not include the price on contact lenses, outside of diagnostics, and are as follows:

Level 1                    $ 99         Soft spherical single vision contact lenses

Level 2                    $159        Soft toric single vision contact lenses requiring follow-up visit(s)

Level 3                    $199        Multi-focal or mono-fit soft contact lenses, extended range astigmatism
                                            soft toric contact lenses, single vision hybrid contact lenses, single vision RGP

Level 4                    $299        Multi-focal hybrid or RGP, multi-focal soft toric contact lenses, post-RK refit

Level 5                    $399        CRT re-fit

Level 6                    $899        Corneal Refractive Therapy (CRT) initial fitting (over 18 year.),
                                            keratoconus hybrid or RGP, or high myopia (>10 D) medically necessary,
                                            or post-RK initial fitting

Level 7                    $1750       Scleral Lens Fitting

Myopia Management--see separate policy

If you are unsure which level evaluation your eyes require, please address this concern with the doctor prior to proceeding with contact lenses.

I have read and by signing, I understand that if I choose to be fit with contact lenses, I am financially responsible for all fees not covered by my vision benefits.

About Your Insurance

About Your Insurance

Premier Eyecare has contractual agreements in place with insurance companies and/or vision benefit plans which state Premier Eyecare will provide covered services and bill for those services appropriately. The patient has a contractual agreement in place with their insurance provider and/or vision benefit provider which entitles them to some extent of coverage and/or benefits with the use of their plan. Premier Eyecare does not work for the patient's insurance company and/or vision benefit plan. As a courtesy to their patients, Premier Eyecare files appropriate claims to insurance companies and/or vision benefits providers for services and materials provided so that debts incurred to Premier Eyecare on the patient's behalf may be met. However, the patient is ultimately responsible for meeting all of their debts incurred with the practice. When a patient disputes an action by an insurance company and/or vision benefit plan, it is ultimately the responsibility of the patient to work with that company to resolve the issue(s).

Both vision benefit and medical insurances cannot be billed on the same date of service without risk of denial and balances being transferred to patients. Our physicians will address the most pressing eye health issue and bill appropriately in their professional judgement, but this may require multiple visits to completely care for your eye health care needs. You will be informed when this is the case whenever possible.

I authorize any holder of medical information about me to be released to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. 

I understand that all fees for products and/or services not covered by insurance and co-pays are due at the time of service. I understand that any balances not covered by my insurance or vision benefit plan will be my responsibility and will receive a statement in the mail. I understand a $30.00 late fee will be added to my account if a remaining balance is not paid in a timely manner and may be transferred to a collection agency. 

I understand that if Premier Eyecare is not a provider with my insurance or vision benefit plan, I can submit my own claim for reimbursement of the fee I paid in the office.

I have read and accept these policies.

Retinal Imaging

Dilation of the pupils:

Dilating the pupils is still considered the "standard-of-care" for examining the tissues of the eyes. Eye drops are used to temporarily relax the iris muscles in order to prevent the pupils from constricting when light is presented to the eyes. This recommended for everyone having a comprehensive eye exam.

HD Retinal Photography:

Our wide-angle retinal camera (Optos Daytona) allows for high-definition images of the back of your eyes. This assists the doctor in examining the eyes and utilizes technology to see structures in the eyes which may be missed without dilation. This is also an excellent way to document the images in your record for future reference if needed.

OCT (Optical Coherence Tomography)

OCT provides a view of the retinal layers in the macular area. Without it, only observation of the top layer of the retina is possible. Think of a layered cake. If you only see the top layer of icing, you will miss all of what is inside the cake. Many pathologies occur beneath the surface of the retinas; therefore, it is important to examine this area thoroughly.

Premier Eyecare highly recommends a combination of these tests in order to receive the most thorough evaluation of your retinal health.

Please read and sign at the bottom showing that you have an understanding of the following:

                * I understand that a complete retinal health evaluation is not covered by health insurances and has an additional fee of $79.00.

                * I understand that dilation is included with my exam and will not have an additional fee.

                * I understand that by refusing dilation and retinal imaging I am going against the doctor's recommendations and will not hold the doctor responsible for any pathology that is missed due to a lack of diagnostic information that could have been obtained by using the aforementioned options

Please notify the technicians at your appointment which option you would prefer for your eye health examination.

Optical Policies

Doctors Changes: Premier Eyecare will honor a one-time prescription lens change made by a doctor for 60 days following the original order at no charge. If the prescription was not written by one of our doctors and you would like our doctors to check the prescription, a refraction fee of $55 will apply. Otherwise, you will return to your doctor at their discrection.


Non-Adapts: In the event a patient does not adapt to a new lens design within 60 days, Premier Eyecare will remake the lenses one time at no additional charge. However, as we have already been charged for the lenses, no refund will be given for the price difference in materials.


Refunds/Exchanges: We cannot offer refunds on eye exam services or goods, including lenses, frames, sunglasses, and contact lenses. If a circumstance warrants any type of exchange, a store credit will be issued when necessary.


Troubleshooting: We do not troubleshoot eyewear purchased outside of our establishment. If the prescription was written by one of our doctors, we will gladly check that the prescription was made as prescribed.


Adjustments: Adjustments on glasses that were not purchased at our establishment are at your own risk.


Patient’s Own Frame: The age and condition of your old frame could lead to breakage which Premier Eyecare is not responsible for replacing. Should your frame become damaged or broken after new lenses are purchased you may be responsible for the purchase of a new complete pair.


Repairs: We are happy to clean and service all our products including minor in house repairs, such as replacing screws and nose pads, at no charge. We strongly recommend taking advantage of our Platinum Warranty for new frames or lenses purchased at Premier Eyecare, which warrants any damage for one year from the original date of purchase. 


By signing, I understand and agree to the optical policies as outlined by Premier Eyecare.

Medical Information Release Form

Communication and Messages (check all that apply)
Okay to call: *
Okay to text *
Okay to email:
If unable to reach me: *
This Release of Information will remain in effect until terminated by me in writing.

Consent For Use Or Disclosures Of Health Information

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