Returning Patient Form

Welcome back to our office

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.

I understand that verification of coverage & authorizations must be obtained PRIOR to Eye exam.

NOTE: We are providers for Eyemed vision plans. Please present your Eyemed card (or Aetna discount plan #) and valid picture 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.

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.