Hours

M 8:00 - 6:00

T 9:30 - 6:00

W 1:30 - 6:00

Th 9:30 - 6:00

F 8:00 - 6:00

Bright Eye Care &

Vision Development

During the last week, have you experienced eyes that feel gritty? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

Name and Phone Number of Primary Care Physician/Pediatrician *

Today's Date *

How Your Insurance and Eye Exam Work

Date I signed the How Your Insurance and Eye Exam Work document *

During the last week, have your eyes felt uncomfortable while in places or areas with low humidty (very dry)? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

During the last week, have you experienced blurred vision? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

During the last week, have you experienced eyes that are sensitive to light? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

Date that I signed and consented to the COVID-19 Release as stated directly above: *

During the last week, have problems with your eyes limited your ability to watch TV? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

During the last week, have you experienced poor vision? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

During the last week, have you experienced eyes that are painful or sore? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

During the last week, have your eyes felt uncomfortable while in windy conditions? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

A dilation during a yearly eye exam will not check for diabetes, glaucoma, high blood pressure or other specific diseases in the eyes. If you are concerned with diabetes in the eyes or any other specific eye disease, you will need to schedule a separate office visit to investigate those concerns. Routine vision insurance does not provide coverage for the evaluation of eye diseases. Diagnoses will not be made. *

Go forward with the general dilation

Decline the general dilation

Schedule a separate office visit

During the last week, have your eyes felt uncomfortable while in areas that are air conditioned? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

During the last week, have problems with your eyes limited your ability to read? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

During the last week, have problems with your eyes limited your ability to work at a computer or bank machine (ATM)? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

During the last week, have problems with your eyes limited your ability to drive at night? *

All of the time (4)

Most of the time (3)

Half of the time (2)

Some of the time (1)

None of the time (0)

Be entering my name below, I understand & agree with the How Your Insurance and Eye Exam Work document. *

COVID-19 Release: Even with increased safety measures, there is an inherent risk of being exposed to COVID-19 whenever you are in a public place and people are present. COVID-19 can lead to severe illness and death. By visiting the office, you assume all risks associated with exposure to COVID-19. By entering my name below, I agree (if the patient is a minor, please have a parent or guardian sign off on this COVID-19 Release). *

If the "Submit" button is a very light color, then there are still required (*) questions that have not been answered. Please go back and finish answering those questions. Upon successful submission, you will be re-directed to a different page.

Insurance & Fee Responsibility Agreement

Date I signed the Insurance & Fee Responsibility Agreement *

I agree with and will comply with the Insurance & Fee Responsibility Agreement *

Has your vision or medical insurance changed? *

Yes

List of allergies (medicines, foods, seasonal) *

If your vision or medical history has changed, please explain.

List of current medications *

Subscriber Last 4 of Social Security #

Medical Insurance I.D.

New Medical Insurance Company & Phone

Subscriber Name & DOB (xx/xx/xxxx)

Vision Insurance ID

New Vision Insurance Company & Phone

Phone (cell)

Check here to receive email updates

What is the major purpose of this visit?

Patient DOB (xx/xx/xxxx) *

Patient First & Last Name *

Guarantor First & Last Name (if different than Patient)

Address (street, city, state, zip) *

Welcome Back

Thank you for choosing us again for your eye care needs. Please take a few moments to update your information so that we can be ready for you when you first arrive. If you are completing this on your smartphone, please use Safari for the i-Phone and the stock Android browser for your Android phone.