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Patient Registration Form

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The doctors and staff are pleased to welcome you to Commerce Family Eyecare. Please fill out this form as completely as you can. If you have any questions, it will be our pleasure to assist you. We look forward to working with you to maintain your visual health!
Patient Name *
Date of Birth *
Gender
*
Preferred #
Mailing Address
Check all that apply (Reason for visit)

Diagnosis History

Macular Degeneration: Self or Family?
Cataracts: Self or Family?
Glaucoma: Self or Family?
Diabetes: Self or Family?
Hypertension: Self or Family?
High Cholesterol: Self or Family?
Cancer: Self or Family?
Heart Disease: Self or Family?
Thyroid: Self or Family?
Stroke: Self or Family?
Retinal Detachment: Self or Family?

Insurance portion MUST be completed if Commerce Family Eyecare will be filing a claim on your behalf.

Insurance Information: Please provide your vision AND medical insurance information below, and any supplemental insurance you may have; if applicable.

Is Commerce Family Eyecare filing your insurance on your behalf today? *
(The information I have provided is accurate to the best of my knowledge.)

I authorize the following individuals to have access to my records:

Office Policies

  • Payment for all services and products are due at the time services are rendered. Product will NOT be ordered without payment. There are NO refunds on services rendered or products ordered.
  • We are more than happy to file your insurance claim on your behalf. However, should any issues arise due to coverage, we cannot act as a mediator between you and your insurance carrier and/or employer.
  • If you are unable to provide your insurance at time of service, you are responsible for all monies due. We CANNOT file a claim to your insurance after the fact.
  • If you are unable to keep your scheduled appointment, we do require notification at least 1 business day before. Failure to do so will result in a $50 No Show/Same Day Cancellation Fee. Please note that any patient with more than 1 no shows/same day cancellations in a 1 year period will no longer be able to schedule an appointment, but may be seen as a same day work-in appointment depending on availability.
By signing below, I understand the following:
Policy Acknowledgements *
I have read and agree with this policy.
Date *
*
*

Optomap® Retinal Exam

During an annual eye exam, your doctor utilizes the Optomap ultra-widefield retinal exam to monitor for complications including macular degeneration, diabetic retinopathy, glaucoma, and retinal holes or detachments. These problems can develop without warning and sometimes with no signs or symptoms.

This state-of-the-art technology allows your doctor to see small details that can assist with detecting systemic problems unrelated to the eye such as diabetes, hypertension, cancer/tumors, auto-immune disorders, and others.

The Optomap Retinal Exam:

  • Is as fast as taking a picture.
  • DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, potentially eliminating a 30-minute wait and avoiding side effects such as blurry vision and light sensitivity.
  • Saved in your file enabling our doctors to make important comparisons during your annual eye exam.

This is a REQUIRED part of our routine eye exam, and there is a $39.00 fee for the Optomap Retinal Exam.

Optomap Consent *
Date *
*
*