Online Check-In

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Patient Name*

Gender

Last 4 SS#*

Address (Street, City, Zip Code)

Date of Birth*

MM slash DD slash YYYY

Primary Phone*

Secondary Phone

Email*

Employer/Occupation*

Marital Status

Date of Last Eye Exam

Primary Care Physician Name / Location

Are you here for ...

Glasses

Contacts

Both

Medical Information and History

# alcoholic drinks per week

Tobacco / Vape Use?

Pregnant or nursing?

Any Eye Infections/Diseases? Injuries/Surgeries

Interested in refractive surgery?

Yes

Type of Contacts Worn

Type/Brand CL Solutions Used

List ALL Medication Taken

List ANY Allergies

Please mark if you or any blood relatives have been or are currently diagnosed with any of the following:

Macular Degeneration

Self

Mother

Father

Grandparent

Sibling

Glaucoma

Self

Mother

Father

Grandparent

Sibling

Color Deficiency

Self

Mother

Father

Grandparent

Sibling

Lazy Eye

Self

Mother

Father

Grandparent

Sibling

Migraines

Self

Mother

Father

Grandparent

Sibling

Cancer

Self

Mother

Father

Grandparent

Sibling

Stroke

Self

Mother

Father

Grandparent

Sibling

High Blood Pressure

Self

Mother

Father

Grandparent

Sibling

High Cholesterol

Self

Mother

Father

Grandparent

Sibling

Diabetic (Type 1 or 2)

Self

Mother

Father

Grandparent

Sibling

If you are diabetic. What type, and what was your last A1C?

Is there any other information that will help the doctor and/or staff with your exam? (conditions, disabilities, limitations, etc.)

HIPAA Notice of Privacy Practices - Acknowledgement of Receipt

The privacy of your medical information is important, and we are committed to protecting it. To provide you with quality care and to meet federal legal requirements, we have created a record of the and services you have and will receive at Columbus Optical. If you would like a copy of the full-length Privacy Policy, please request it from the front desk.

Patient Name*

I agree and I hereby acknowledge that I have been notified of ColumbusOptical's commitment to protecting my medical information and offered access to the HIPAA Private Practices.

If you would like us to release information about your health to any one besides yourself, please list them below:

Name, Relationship, Contact Number

If you do not wear contact lenses and/or not interested in contact lenses, please disregard this section.

Contact Lens Fitting Program

All insurances list contact lens fitting and exam fees separately from your comprehensive eye examination. These fees cover additional time, testing and measurements required by the doctor and staff for your personalized contact lens prescription. It also includes any trial lenses and follow up appointments within 60 days of the initial evaluation. Like glasses, contact lens prescriptions are renewed yearly and require re-examination. Some vision plans may contribute toward the fitting fee and?or contact lens supply fees. See Columbus Optical pricing below:

Standard Fit (ex: current CL wearer with no changes)$65.00
Premium Fit 1 (ex: First Time Wearer): $105.00
Premium Fit 2 (ex: complex prescription, multifocals, RGP)$155.00
Medically Necessary Fit (ex: scleral lenses, extreme rx's not corrected by glasses):$250.00+
Additional Contact Lens Training Insertion and Removal as Needed $35.00

If you purchase an annual contact lens supply from Columbus Optical, we will be happy to provide trials to wear if yo run out prior to your next scheduled comprehensive exam. Additionally, we will exchange unopened and unaltered (not written on) boxes of contacts if you experience a doctor approved prescription change during the year. This exchange is 1 to 1 and patient is responsible for any cost difference per box.

I agree

I have read the information above regarding the Successful Fit Contact Lens Program and agree to the Contact Lens Professional Fee. I also acknowledge that I will be provided with a copy of my contact lens prescription at the completion of my fitting.

Appointment Late/No Show Policy

Any patient who arrives more than 15 minutes past the scheduled appointment time will be asked to reschedule. Any Patient who arrive up to 15 minutes past the scheduled appointment time may be asked to reschedule if they have not completed their patient paperwork prior to arrival. Seeing any patient past the scheduled appointment time will be at the doctor's discretion. After TWO no-show appointments without contacting the office: Patient will be required to make a non refundable $35.00 deposit. This amount can be used towards exam fees at the completion of the exam.

As a courtesy, we attempt to make reminder calls for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect.

We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our office, and we may be able to waive the No Show fee. You may contact Columbus Optical at the number below. Should it be after regular business hours, you may leave a message. Columbus Optical Services Doctors Line: 812-372-7782

I agree*

I have read and understand the Appointment Late/No Show Policy and agree to its terms.

Office Financial Policy

As a small business, we are not on a billing system and therefore require payment at the time of service. If we agree to submit claims to your third-party insurance carrier, we will do so within two business days and in a standardized format per the third-party regulations. If services are not covered in full, the responsibility will return to you, the patient or legal guardian, in addition to any co-payments, co-insurance fees, or applicable deductibles less any contractual agreements between the third-party and Columbus Optical. Responsibility will also fall to the patient should any fees occur due to non-payment including but not limited to attorney fees, court fees, and collections. Due to the expense of issuing refunds, we will not automatically return overpayments less than or equal to $15 but will credit the appropriate patient account to be used towards your next visit with us. Should you prefer all overpayments to be returned to you, no matter the amount, please speak to a staff member.

I Understand*

I have read the above financial agreement and understand.

Company

This field is for validation purposes and should be left unchanged.

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Appointment Request

Please fill out the following form with your appointment preferences. We will reach out via your preferred contact method to finalize appointment details by the end of the next business day. See you soon!

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Have you had an exam in the last 2 years?(Required)

Preferred Contact Method(Required)

Phone(Required)

Email(Required)

What day(s) of the week work best?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Choose all that apply

What time(s) of the day work best?(Required)

8:00-10:00

10:00-12:00

12:00-2:00

After 2:00

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Are you interested in glasses or contacts?(Required)

Glasses

Contacts

Both

Will you be using vision insurance? If so, who is your provider?