Patient Form

Patient Information

Full Name *

Date of Birth

Email Address

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Health and Eye Conditions

Family History

Financial Policy

The doctor and staff at Gun Barrel Family Eyecare are pleased that you have chosen us for your eyecare needs.
Please review our financial policy and acknowledge it with your e-signature below.

1. Payment for professional services (eye examinations, specialty testing, medical visits) is due the day services are provided. Payment for eyeglasses and contact lenses is due in full the day materials are ordered. For your convenience, we accept cash, debit cards, Visa, Mastercard, Discover and Care Credit.

2. Eyeglasses are customized products and all optical sales are final.

3. Payments for copays, deductibles, and items known not to be covered by your insurance is due at the time of your visit. You are ultimately responsible for all charges for which your insurance company denies payment when we receive your Explanation of Benefits statement from them. Payment is due within 30 days after having been notified by your insurance and/or providers.

4. In the event that we do not participate with your Vision Plan or Medical Insurance, payment is due in full when services are rendered. We will provide you with an itemized receipt so that you may file with your carrier for reimbursement.

5. Both established and new contact lens wearers are subject to a contact lens medical evaluation and fitting fee. This fee is due at the date of the initial evaluation.

6. For those with Flexible Spending Accounts, payment in full is due for services rendered and materials ordered. An itemized statement that can be submitted to your insurance company for reimbursement will be given to you at the time of your visit.

7. If payment from your insurance company has not been received in 60 days, you will be responsible for paying your account balance in full.

8. Finance charges at the rate of 1.5% (18% APR) will accrue on all outstanding balances.

9. In some families, the question of who is responsible for a child's bill is uncertain. Since we are not partyto any separation agreement or court order, this is strictly a matter between parents. We must insist, therefore, that the parent who requests evaluation and treatment for the child will be responsible for all fees incurred.

10. If our office pursues legal action to collect unpaid charges, you will be billed the cost of attorney fees, courts costs, and collection fees in addition to any unpaid balances.

I have read and understand the above information and agree to the terms set forth in this agreement.
I understand that if I fail to make any payments my account may be turned over to a collection agency.

Signature *

Permission for Telehealth Visits

What is telehealth?
Telehealth is a way to visit with healthcare providers, such as your doctor or nurse practitioner.

How do I use telehealth?

  • You talk to your provider by phone, computer, or tablet.

  • Sometimes, you use video so you and your provider can see each other.

  • Can telehealth be bad for me?

  • You and your provider won’t be in the same room, so it may feel different than an office visit.

  • Your provider may decide you still need an office visit.

  • Technical problems may interrupt or stop your visit before you are done.

Will my telehealth visit be private?

  • We will not record visits with your provider.

  • If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.

  • Your provider will tell you if someone else from their office can hear or see you.

  • We use telehealth technology that is designed to protect your privacy.

How much does a telehealth visit cost?

  • What you pay depends on your insurance.

  • A telehealth visit will not cost any more than an office visit. • If your provider decides you need an office visit in addition to your telehealth visit, you may have to pay for both visits.

What does it mean if I sign this document?
If you sign this document, you agree that:

  • We talked about the information in this document.

  • We answered all your questions.

  • You consent a telehealth visit

Signature *

Contact Lens Prescription Signed Acknowledgment Form

The Centers for Disease Control and Prevention (CDC) makes clear, “Contact lenses can provide many benefits, but they are not risk-free—especially if contact lens wearers don’t practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment.”

The CDC recommends the following for contact lens wearers:
✓ Schedule a visit with your eye doctor at least once a year.
✓ Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision.
✓ Understand that eye infections that go untreated can lead to eye damage or even blindness.

The Food and Drug Administration (FDA) indicates:
✓ “To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It’s safer to be re-checked by your eye care professional.”

Symptoms of Eye Infection include:

  • Irritated, red eyes

  • Worsening pain in or around the eyes—even after contact lens removal

  • Light sensitivity

  • Sudden blurry vision

  • Unusually watery eyes or discharge

Sign below to acknowledge that you were provided with a copy of your contact lens prescription at the completion of your contact lens fitting.

Signature *

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