New Patient Information and Consent Form

Patient Name *

First Name Middle Name Last Name Suffix
Preferred Name
Patient Gender *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

SSN *
Patient Birth Date *

Month Day Year
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email
How did you hear about our office?
Please check your preferred method of contact for appointment confirmation:

E-MAIL CELL PHONE (call) HOME PHONE CELL PHONE (text)
Insurance - Primary
Health Insurance Workers Comp Auto Accident None
Insurance Company Name
Insurance Company Address
Insurance Company Phone

Area Code Phone Number
Claim Number
Date of Accident/Injury

Month Day Year
Date Picker Icon
Subscriber ID
Group Number
Insurance - Secondary
Health Insurance Workers Comp Auto Accident None
Insurance Company Name
Insurance Company Address
Insurance Company Phone

Area Code Phone Number
Claim Number
Date of Accident/Injury

Month Day Year
Date Picker Icon
Subscriber ID
Group Number
Doctor Information

We cannot submit any services to insurance without a doctor's prescription and medical notes. Please provide this information so that we may contact your doctor.
Do you have a personal physician (PCP)?

Yes No
Physician's Name
Physician's Phone

Area Code Phone Number
Date of Last Visit
Do you have an ophthalmologist?

Yes No
Physician's Name
Physician's Phone

Area Code Phone Number
Date of Last Visit
Medical History
Which side is the afflicted eye?

Left Right Both
How did you lose/injure your eye(s)?
In 500 letters or less
Was your eye removed (enucleated) or eviscerated?

Yes, enucleated Yes, eviscerated No, my eye is still there
Date of enucleation/evisceration surgery?
Doctor who performed the surgery?
Do you currently wear an artificial eye or scleral cover shell?

Yes No
How old is your current prosthesis?
Are you currently having any issues or concerns?
When was your last polish/cleaning?
How can we accommodate you better during your visit?
Office Policies
FINANCIAL POLICY We realize that every person’s financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the care you need with respect to your budget. Health Insurance At this time, Advanced Ocular Prosthetics Inc. accepts all Blue Cross/Blue Shield insurance plans as well as all UPMC Health Plans. You, the patient, are responsible for all deductible and co-insurance under your plan. If you have a different insurance plan you are responsible for the full amount of all services provided by Advanced Ocular Prosthetics Inc. We are happy to file the forms necessary to see that you receive the full benefits of your insurance coverage, however we cannot guarantee payment. Because the insurance policy is an agreement between you and the insurance company, we must emphasize that as a specialty provider our relationship is with you. Please know that we will do everything possible to see that you receive the full benefits of your policy but ultimately you, the patient are responsible for all charges. If your insurance company pays AOP, we will promptly refund any overpayment to the patient. Payment For your convenience, AOP accepts cash, check, Visa, MasterCard, Discover and Care Credit, which offers interest free payment plans. All payments, including deductible and co-insurance, are due the day of your appointment. *
AUTHORIZATION AND RELEASE I authorize AOP to release any information and/or records of my care to third party payers. I hereby assign AOP all insurance benefits, including major medical benefits, due in consideration of the ocular prosthetic and it’s care that I have received or will be receiving. I hereby authorize my insurance company(s) to pay benefits directly to AOP. I agree to be responsible for all charges not covered by my insurance. I also understand that failure to receive proper physician authorization may result in denial of benefits. *
CONSENT FOR TREATMENT I, the undersigned, hereby authorize the ocularist at Advanced Ocular Prosthetics Inc. to furnish such examination, fitting and outpatient care which in the physician’s judgment is recommended or necessary for the treatment of any illness or condition. *
PHOTOGRAPHY RELEASE We routinely take pictures of our patients. We do this in order to keep record of our patients and their prostheses. Sometimes we use these photos for lectures or presentations that are purely for educational purposes. By initialing here, you are stating that it is acceptable for us to use your photos for educational purposes. This includes promotional material and social media. *
Anything else we need to know?
Signature *

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Insurance - Primary

Insurance - Secondary

Doctor Information

Medical History

Office Policies