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Home » Our Eye Care Clinics in Rockledge & Merritt Island, FL » Merritt Island Patient Information Form

Merritt Island Patient Information Form

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • (We use text messaging for appointment reminders & to let you know when glasses or contacts are ready)
  • (We will send your exam results. Please send response when received)

  • Optomap

    Optomap ultra-widefield retinal imaging is an advanced technology that provides a 200 degree digital retinal image. This allows our doctors to see far more of your retina through the undilated eye than is possible using standard technology. Our doctors recommend the optomap for ALL our patients at every exam.

  • Dilation

    We may need to install drops to examine the inner wall of your eyes. These drops may cause some sensitivity to light and blurred vision.

  • Notice of Privacy Practices

    I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
    A basis for planning my care and treatment
    A means of communication among the many health professionals who contribute to my care
    A source of information for applying my diagnosis and surgical information to my bill
    A means by which a third-party payer can verify that services billed were actually provided
    And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

    I have been provided with a Notice of Privacy Practices that gives a more complete description of information uses and disclosures as well as a description of my privacy rights. I understand that I can review the notice prior to signing this acknowledgement. I understand that the organization reserves the right to change their notice and practices and will provide me a copy of any revised notice.
    By signing below you acknowledge that a full copy of our HIPAA form is available to you on our website

  • We reserve the right to charge $50.00 for appointments missed without 48 hours notice. Accounts over 90 days past due are subject to a $25.00 late fee.
    In the event my account is referred to collections, I agree to pay all costs of collection, including but not limited to reasonable attorney’s fees.

    I have reviewed and understand the information contained on this form.
  • Eye Health History

  • (type)
  • Medical History

    Please check off any conditions you have had
  • Family Health History

  • Social History