Call Us Today at: 770-978-2020
Heritage Village (Hwy 78 and Oak Rd)
2427 Main St.
Snellville, GA 30078

Follow Us  Facebook
Text Size

Patient Information Form

Heritage Vision center Logo
2427 Main St., Snellville, GA 30078 (770) 978-2020
Conveniently located in Heritage Village (At Hwy 78 and Oak Rd near Snellville City Hall)

Please call for an appointment or use our Request an Appointment Form

Click on calendar to fill in Today's date
Salutation
Invalid Input

Last Name
Invalid Input

First Name
Invalid Input

Telephone #(*)
Invalid Input

E-mail(*)
Invalid email address.

Address
Invalid Input

City
Invalid Input

State
Invalid Input

Zip code
Invalid Input

SSN
Invalid Input

Occupation
Invalid Input

Employer
Invalid Input

Date Of Birth
/ / Invalid Input

Age
Invalid Input

Invalid Input

Emergency Contact
Invalid Input

Relation
Invalid Input

Emergency Contact Phone Number
Invalid Input

Medical Insurance Information
Primary Member
Invalid Input

Relationship to Member
Invalid Input

Member SSN
Invalid Input

Member Birthdate
/ / Invalid Input

Medical Provider
Invalid Input

(BCBS, Humana, Medicare, etc)

Member ID
Invalid Input

Vision Insurance Information
Vision Provider
Invalid Input

(EyeMed, VSP, Davis Vision, etc)

Vision Medical ID
Invalid Input

 
Elective Retinal Imaging and iWellness Screening
In addition to your basic exam today, we offer advanced screening and testing options to our patients. These screening procedures are usually not covered by your insurance and would be added charges the day of your visit.
Retinal Images are quick painless and non invasive. As a diagnostic tool retinal images provide high resolution, permanent records of the back of the inner eye.Retinal images take place of having to be dilated. This will eliminate any side effects like blurry vision and light sensitivity that may aoccur with dilation.
iWellness Exam (OCT) One of the procedures provided by our practice is Optical Coherence Tomography, also know as OCT. THis painless non invasive procedure allows us to examine the various layers behind the eye in cross sectional views.
This test similar to an ultrasound helps detect and monitor a varety of eye conditions such as macular degeneration, Glaucoma, and various retinopathies. results become part of your medical record with us, and can help our Doctors treat these issues up to 5 years sooner.
Both Retinal Imaging and IwellnessExam is an eligible expense for Flexible Savings accounts.
Please Choose your Screening Option

Invalid Input

 
ALL INFORMATION IN THIS CASE HISTORY IS CONFIDENTIAL
How did you hear about us?
Invalid Input

Please let us know who referred you or how you found us.
Invalid Input

DATE OF LAST EYE EXAM
Invalid Input

REASON FOR TODAY’S VISIT (CHIEF COMPLAINT OR NEED)
Invalid Input

I would like an exam for:

Invalid Input

Do you have a personal or family history of :
Invalid Input

If you checked any above please explain:
Invalid Input

Please list all medical conditions that you have, even those not related to eyes:
Invalid Input

Wear Prescription Eye Glasses
Invalid Input

Wear Prescription Sun Glasses
Invalid Input

Wear Computer Glasses
Invalid Input

Wear Sports Glasses
Invalid Input

Wear Contact Lenses
Invalid Input

If yes, then which brand are you using?
Invalid Input

Current Contact Lens Prescription-Right
Invalid Input

Current Contact Lens Prescription-Left
Invalid Input

Is your comfort level:
Invalid Input

 
Patient Acknowledgement of Notice of Privacy Practices
As required by the standards of the Health Insurance portability and Accountability act of 1996 (HIPPA)
I have received a copy of the notice of Privacy Practices of Heritage Vision Center on the date indicated below.
I understand that if any changes are made to this Notice of Privacy Practices, a revised copy of the notice will be posted in the office of Heritage Vision Center.
I also understand that if I wish to receive additional copies of this Notice of Privacy Practices in the future or if I have any questions with regard to this notice of Privacy Practices, I may contact Heritage Vision Center.
Patient Consent for use and Disclosure of Protected Health Information
I hereby give my consent for Heritage Vision Center to use and disclose protective health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Heritage Vision Center Notice of Privacy Practices provides a more complete description of such uses and disclosures.
I have the right to review the notice of Privacy Practices prior to singing this consent. Heritage Vision Center reserves the right to revise its notice of privacy practices at anytime. A revised Notice of privacy practices may be obtained by forwarding a written request to:
Heritage Vision Center
Attention: Compliance Officer
2427 Heritage Village, Ste # 4
Snellville, GA 30078 770 978-2020

With this consent, Heritage Vision Center may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointments reminders,insurance items and any calls to my medical clinical care.
With this consent, Heritage Vision Center may mail or email to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminders and patient statements.
I have the right to request that Heritage Vision Center restricts how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by the agreement. By signing this form, I am consenting to Heritage Vision Center’s use and disclosure of my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Heritage Vision Center may decline to provide treatment to me.

Snellen Eye Chart

Secure Socket layer Installed

Designed by FreedmanDesignGroup.com