Online Registration Form - Statesville Office

Please note: This is NOT sent via a secure server. (Our online registration is sent to a restricted e-mail address in each office, but the data is NOT sent via a secure server.)

Please fill out this form online and press "submit" or print out and bring with you to your visit at ECC Statesville. All information will be kept confidential. Having this form completed before you arrive in our office will decrease your wait time in our office.

Yes No

Do you have an appointment scheduled?

Yes No

If yes, what is the date for which your appointment is scheduled?

-- dd/mm/yy

Personal Information:

First Name
Last Name
Middle Initial
Date of Birth
Sex	Male Female

Please provide the following contact information:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Employer
Work Phone
Home Phone
E-mail

How do you prefer to be contacted for additional information?

Insurance Information:

Insurer:

Policy #

Group #

Your relationship to insured:

How did you find our practice?

Friend
Insurance
Employer
Yellow Pages
Newspaper
Internet
Direct Mail
Other

Approximately when was your last eye examination

Who was your last eye doctor?

Have you ever worn?

glasses
contact lenses

Are you interested in...?

contact lenses
prescription sunglasses
new glasses
new lens technology
30-day continuous wear contacts
changing your eye color
LASIK or other refractive procedures
Optos non-dilated eye examination

Ocular history (YOU): Check all that apply:

headaches
double vision
eye turn
eye surgery
eye injury
itching
redness
burning
gritty/sandy feeling
eye pain
floaters
flashing lights
glare
blurry vision
visual distortion
eyelid problems
lumps/bumps

Please select any of the following systems with which you now have or have had difficulties (review of systems):

Gastrointestinal
Ear/Nose/Throat
Cardiovascular
Respiratory
Nervous
Genitourinary
Musculoskeletal
Skin
Mental
Endocrine (glands)
Blood/lymph
Allergic/immunologic

Please select all that apply to your FAMILY history:

Hypertension
Diabetes
Glaucoma
Macular degeneration
Retinal detachment
Eye degeneration
Cataracts
Thyroid disease
Blindness
Stroke
Cancer
Heart Disease
Kidney disease

Please list medications you are taking...

Are you allergic to any medications?

Yes No

If yes, please list medication allergies:

Please list operations you have had (if any):

Do you use cigarettes/tobacco?

Yes No

Do you/have you had substance abuse problems (including alcohol)?

Yes No

Who is your family doctor?

Is there any other health information we should know?

Please list medical conditions for which you have been treated in the past two years:

Payment Policy

Payment for professional services is due upon completion of services. Spectacles and contact lenses require a 50% deposit before ordering. The balance on materials is due when the materials are dispensed. We do not bill services or materials. We do accept assignment on many insurance plans. If we do not accept assignment on your insurance plan, we will file the necessary paperwork so that payment for covered services and/or materials can be sent to you by your insurance company.

You are ultimately responsible for all charges incurred in our office, including charges for services and/or materials rejected or not covered by insurance (authorization and verification of benefits is NOT a guarantee of payment). If we must resort to collection agencies or the court system to collect unpaid balances, you will be responsible for costs incurred in such collection.

Please read the following statements and sign (click) below:

I have read the payment policy above and agree to the terms as stated.

I have read the Notice of Privacy Practices and agree to the terms.