Returning Patient Form

Name: Bob Ham Eyewear
Address: 9965-24 San Jose Blvd, Jacksonville, FL, 32257, US
Price range: $000 - $300

Welcome back to our office
Please update your information for our records. Thank you.
Name
First Middle Last
Date
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Reason for today's visit
Do you desire a contact lens exam today?
For All Patients to Sign
HIPPA (Health Information Privacy and Portability Act): Please read the office HIPPA policy that's attached to the clipboard.

Signature below is only acknowledgement that I have seen and read this policy.
Patient (or guardian) signature
Date
Date Format: 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 (or guardian) signature
Date
Date Format: 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 front desk.
Eyemed Plan Name
Policy #
Patient's Social Security
Patient's DOB
Date Format: MM slash DD slash YYYY
Responsible member : Name
Birthdate
Date Format: 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
Date
MM
DD
YYYY
Dilation
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.
- I can have this procedure today.
- I am unable to do this procedure today and need to reschedule it.

Welcome back to our office

For All Patients to Sign

For those with Vision Insurance

Dilation

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