Welcome to The Vision Hub! Please complete all sections of this registration form as thoroughly as possible. Your information helps us provide the best possible eye care for you and your family. All information is kept strictly confidential.
If you have any questions while completing this form, please don't hesitate to ask a member of our staff.
Complete this section if the patient is a minor (under 18 years of age) or requires a legal guardian.
Please provide your primary vision and/or medical insurance information below.
Please check if any blood relatives have been diagnosed with the following:
Please list all prescription and over-the-counter medications, eye drops, vitamins, and supplements you currently take.
A contact lens examination and fitting is a separate service from a comprehensive eye exam. By signing below, I understand and agree to the following:
1. Separate Service Fee: A contact lens fitting fee will be charged in addition to the comprehensive eye examination fee. This fee covers the evaluation, fitting, and any follow-up visits required to ensure proper lens fit and prescription.
2. Trial Lenses: Trial contact lenses may be provided during or after the fitting appointment. These lenses remain the property of The Vision Hub until a final prescription is issued.
3. Prescription Requirements: A valid contact lens prescription requires a successful fitting and follow-up evaluation. Contact lens prescriptions are valid for one (1) year from the date of the fitting.
4. Compliance: I agree to follow all care instructions provided by my eye doctor regarding proper wear, care, and replacement of my contact lenses. I understand that failure to comply may result in eye health complications.
5. Financial Responsibility: I understand that insurance may not cover contact lens fitting fees and that I am responsible for any balance not covered by my insurance plan.
Pupil dilation is an important part of a comprehensive eye examination. Eye drops are used to temporarily enlarge the pupils, allowing your doctor to thoroughly examine the internal structures of the eye, including the retina, optic nerve, and blood vessels.
What to expect: Dilation drops may cause temporary blurred near vision and increased light sensitivity lasting 2–6 hours. You may wish to bring sunglasses to your appointment and consider arranging a driver, as driving may be difficult immediately after dilation.
Risks: There is a rare risk of an allergic reaction or an acute angle-closure glaucoma attack associated with dilation. Please inform the doctor of any known allergies or prior reactions to eye drops.
Optomap® ultra-widefield retinal imaging provides your doctor with a detailed digital image of the retina — the back of your eye. This cutting-edge technology allows early detection of conditions such as retinal tears, macular degeneration, glaucoma, diabetic eye disease, and other systemic conditions.
Benefits: The Optomap captures up to 82% of the retina in a single image without the need for dilation in many cases. Images are stored in your permanent records for future comparison.
Fee: Optomap retinal imaging is an elective service that typically is not covered by vision insurance. A fee will apply. Please ask our staff about current pricing.
No risks: Optomap is a non-invasive, painless procedure with no known risks or side effects.
I hereby authorize The Vision Hub to bill my insurance company/companies listed on this form for services rendered. I understand the following:
Assignment of Benefits: I assign all insurance benefits, including major medical benefits, to which I am entitled directly to The Vision Hub. This assignment will remain in effect until revoked in writing.
Co-payments, Deductibles & Non-covered Services: I understand that I am financially responsible for all co-payments, deductibles, and non-covered services at the time services are rendered. I acknowledge that some services may not be covered by my insurance plan.
Insurance Verification: I authorize The Vision Hub to verify my insurance benefits and eligibility. I understand that verification of benefits is not a guarantee of payment.
Coordination of Benefits: If I have more than one insurance plan, I authorize The Vision Hub to coordinate benefits between primary and secondary carriers.
Collection: I understand that if my account becomes past due, I am responsible for all collection fees, court costs, and attorney's fees associated with the collection of my account balance.
I hereby voluntarily consent to optometric examination, diagnostic procedures, and treatment as may be deemed necessary or advisable by the doctors and staff of The Vision Hub.
For Minors: If the patient is under 18 years of age, the parent or legal guardian signing this form confirms they have authority to consent to treatment on behalf of the minor patient.
Understanding of Services: I understand that the doctor will explain the nature of all procedures and treatments before they are performed, and that I have the right to ask questions and to refuse any specific treatment.
Photography / Imaging: I consent to ocular photography and imaging as part of my clinical evaluation. These images will become part of my permanent medical record.
Release of Records: I authorize The Vision Hub to release information from my medical records to other treating physicians, referring practitioners, or as required by law. This authorization does not extend to outside parties not involved in my care without separate written consent.
Telemedicine: In the event that telemedicine services are utilized in my care, I consent to evaluation and consultation through video or digital communication platforms as permitted by applicable law.
Refraction is the test used to determine your eyeglass prescription. During refraction, you will be asked to look through a series of lenses and identify which provides the clearest vision. This test is a critical part of your comprehensive eye exam.
Medicare Notice: Medicare and some other medical insurance plans do not cover routine refraction. If your insurance does not cover this service, a separate refraction fee will be charged.
Separate Fee: A refraction fee may be charged in addition to the examination fee depending on your insurance coverage. Our staff will inform you of any out-of-pocket costs prior to providing this service.
Notice of Privacy Practices: The Vision Hub is committed to protecting the privacy of your health information. Our Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, and healthcare operations, and for other purposes permitted or required by law.
Your Rights: You have the right to: (1) request restrictions on certain uses and disclosures of your PHI; (2) receive confidential communications; (3) access and inspect your health records; (4) request amendments to your records; (5) receive an accounting of disclosures; and (6) receive a paper copy of this notice.
Our Duties: We are required by law to maintain the privacy of your PHI, to provide you with this notice, and to abide by the terms of the notice currently in effect.
Authorized Contacts: Please list individuals below who are authorized to discuss your account, appointments, or health information with our staff.
Please review all sections to ensure accuracy before submitting this form to our front desk staff. Our team will be happy to assist you with any questions. We look forward to taking care of your eye health!
If you have any documents or insurance cards to provide, please present them to our receptionist upon arrival.
* Indicates a required field. Please present completed form to front desk staff.
