Southside Eyecare & Optical

How did you hear about us? * If other, please specify: Patient's Full Name * Mailing Address * Best contact phone number * Is it ok for us to text or email you for accounting or billing purposes? * Patient's Email Address Sex * Date of Birth * Social Security Number Employer * Occupation Race, Language, & Ethnicity Spouse's Name Spouse's Phone Number Spouse's Employer

Emergency Contact

Contact Name & Relationship Phone Number

Primary Insurance

Patient with vision care plans (VSP, MetLife, Eyemed, Davis Vision, etc.) please provide at least the last 4 of your Social Security Number. Patients with no insurance must pay in full at the time of appointment. Estimated Co-pays, co-insurance, or charges not covered by insurance are due at the time of visit.

Please be aware that we do accept VSP, Met Life, Eyemed, Blue View, Davis Vision, Cigna Vision, Spectera but are NOT IN-NETWORK with them. We CAN bill them.

Insurance Company * Member Number or ID Number * Group Number Subscriber * Subscriber's Date of Birth * Subscriber's Relationship to Patient *

Secondary Insurance

Insurance Company (if none, type none or n/a) * Member Number or ID Number Group Number Subscriber Name Subscriber's Date of Birth Subscriber's Relationship to Patient

Health History

Your General Physician Height * Weight * Please check all that apply with correction * Do you wear glasses? * Do you wear contact lenses? * If 'yes' what type of contact lenses? How many hours per day do you wear your contact lenses?

Contact lens prescriptions are valid for 12 months from the completed fit or evaluation. A contact lens evaluation IS REQUIRED every 12 months to obtain a current contact lens prescription. This can be completed by the doctor or the contact lens technician.

Would you like a contact lens evaluation during your visit? * List any other issues with your contacts or glasses: Have you received the flu shot?? * Have you received a COVID-19 vaccination? * If you are 65 years of age or older, have you ever received a Pneumonia Vaccination? If you are 65 years of age or older, have you fallen in the past 12 months? Are you taking any medications, pills, or drugs? * If yes, please list them here: Do you use tobacco? * If yes, please select.... Alcohol Use? * Are you allergic to any of the following? * Do you have, or have you had, any of the following? * Do you have any family history (parents, grandparents, siblings, children; living or deceased) of the following conditions? Please check any that apply. * If you checked any of the above, please list the disease/condition and your relationship with the family member.

Financial Policy

You will be provided with an estimate of the anticipated charges of your care upon request.

Patients are responsible for any balance due if insurance does not pay for any reason. We will not become involved with any dispute you might have with your insurance company. Past due accounts may be subject to a 40% collections fee if referred to a collection agency.

I authorize the release of any medical information necessary to process all claims and I authorize the release of payment for vision/medical benefits to Jan H Nyboer, MD also known as Southside Eyecare & Optical.

There is a $25 fee assesed for any no-show appointment.

I, the patient/guardian, have accurately and truthfully completed the above information and agree that all fees incurred are my responsibility regardless of insurance coverage. I certify that I have read and agree to the patient information and privacy policy of this office.

You represent and warrant that the individual electronically agreeing to the terms of this agreement is authorized and empowered to agree to this agreement on your behalf. You further agree with your name below to acknowledge your assent to this agreement and/or performing any other similar electronic affirmation constitutes an electronic signature as defined by the Electronic Signatures in Global and National Commerce Act and that this agreement is completely valid, has legal effect, is enforceable, and is binding and non-refutable by you.

Signature * Today's Date *