Patient Intake Form

Patient Information

Insurance Information
Vision Insurance
Medical Insurance
Assignment and Release Consent
Payments and Co-Payments
All required payments, co-payments, deductibles, and other out-of-pocket expenses are due in full at the time services are rendered or materials are provided, unless specific financial agreements have been made prior to your scheduled appointment. The office accepts VISA, Master Card, AMEX debit cards and personal checks with proper identification. All personal checks returned for any reason are subject to a $25 service charge without exception. In the event of nonpayment, the cost of collection and or court costs and reasonable legal fees is the responsibility of the patient.
Vision Plan and Insurance Benefits
It is your responsibility to understand the nature of your vision plan and insurance benefits prior to your scheduled appointment. The employees of Carlsbad Optometry will, to the best of their knowledge and understanding, help answer any questions you may have regarding your vision plan and insurance benefits; however, no guarantee of accuracy regarding eligibility, coverage, or benefit information can be made by anyone other than your vision plan or insurance carrier directly.
Assignment of Benefits
I authorize assignment of vision plan and insurance benefits to Carlsbad Optometry for the purpose of determining eligibility, benefits, and collecting for all services rendered and materials provided. In addition, I authorize Carlsbad Optometry and any of its employees to furnish information concerning my present condition to insurance companies and referring doctors as deemed necessary.
Tap the above box to sign (Touch Screen Only)
Medical History
Primary Care
Personal Health History (Do you have any of the following?)
Ocular History
Social History
Ocular History
Reason for Visit