Patient Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

HIPPA (Health Information Privacy and Portability Act): I have read and understand the office HIPPA policy (attached to clipboard). Signature below is only acknowledgement that I have seen and read this policy.

I understand that verification of coverage must be done PRIOR to exam/services. Otherwise, patient will be responsible for filing for insurance benefits.

NOTE: We are providers for Eyemed plans. Please present card & valid ID at front desk.

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.

Below are questions about your ocular and family medical history. Due to your eyes being directly affected by your general health, medical problems, and the medications you take, please answer completely so we can better care for your visual needs.

Although we can determine a spectacle prescription without a dilated fundus 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.