Patient Registration

Our Mission at Bayne Optical is to provide all patients a welcoming environment through superior hospitality while optimizing your vision for life.

In order to minimize transmission of any pathogens we have developed this SECURE online intake (history) form. (You may describe how it is sent if you think it is necessary).

Fever, Tiredness (lethargy) and a Dry Cough are all Symptoms of COVID-19 and other illnesses. If you have those symptoms we respectfully need you to come in on a different day when you're feeling better. We will begin screening your temperature when you arrive for your appointment @ our office. This ensures your health and safety and the health and safety of the Bayne Optical team.

Completing this form gives you a better discount than your insurance. We will decrease our Digital Retinal Imaging cost from $50 to $35.00. The Digital Retinal Imaging allows us to study the health of your eye in detail. Much like an x-ray at your dentist's office.

A Word From Doc Mike From Eye Central About Patient Registration

Patient Registration Form

* indicates required fields.

Patient Information
Name*
First Last
Address*
Street Address City State ZIP Code
Phone
Cell Phone*
Email*
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Hidden
Age
Are you on Social Media?*
- Yes
- No
Who may we thank for referring you to see us today?
Account Information
Name of person responsible for your account
If different than above
First Last
Address
Street Address City State ZIP Code
Home Phone
Work Phone
Last 4 digits of your Social Security Number*
Vision Insurance Provider*
Your Pharmacy
Pharmacy Name
Pharmacy Address
Street Address City State
Pharmacy Phone Number
Payment Information
How will you settle your account today?
- Cash
- Check
- Visa / Mastercard
- Discover
- American Express
- Care Credit
- Health Savings Card
Do you have a Health Savings Account?
- Yes
- No
Do you or your employer participate in a Medical Flex spending account?
- Yes
- No
Personal and Family Medical History
Rx & Over the Counter
Allergies*
- Yes
- Family Member
- No
Arthritis*
- Yes
- Family Member
- No
Asthma*
- Yes
- Family Member
- No
Cancer*
- Yes
- Family Member
- No
Cataracts*
- Yes
- Family Member
- No
Cholesterol*
- Yes
- Family Member
- No
Glaucoma*
- Yes
- Family Member
- No
Diabetes*
- Yes
- Family Member
- No
Eye Disease*
- Yes
- Family Member
- No
Eye Surgery*
- Yes
- Family Member
- No
Heart Disease*
- Yes
- Family Member
- No
High Blood Pressure*
- Yes
- Family Member
- No
Lazy Eye*
- Yes
- Family Member
- No
Skin Disorder*
- Yes
- Family Member
- No
Do you experience...
- Blurry Distance Vision
- Blurry Near Vision
- Burning
- Double Vision Eye Strain
- Dryness
- Fainting or dizziness
- Flashes
- Glare of reflection
- Gritty feeling in eyes
- Headaches
- Itching
- Nausea
- Reading Problems
- Redness
- Sensitivity to light
- Soreness
- Spots
- Sudden loss of Vision
- Trouble learning or reading
- Trouble seeing at night
- Trouble working up close at work, school or leisure
- Uncomfortable contact lenses
- Uncomfortable Glasses
- Watery Eyes
Please describe any other vision problems you might have and want addressed at your next visit.
Current Medicatons
Rx & Over the Counter
Antihistamines*
- Yes
- No
If you know the name of the medication type it in the "Other" field.
Blood Pressure*
- Yes
- No
If you know the name of the medication type it in the "Other" field.
Diuretics (water pill)*
- Yes
- No
If you know the name of the medication type it in the "Other" field.
Eye Drops*
- Yes
- No
If you know the name of the medication type it in the "Other" field.
Oral Contraceptive*
- Yes
- No
If you know the name of the medication type it in the "Other" field.
Sleeping Tablets*
- Yes
- No
If you know the name of the medication type it in the "Other" field.
Please add any other medications, supplements, or vitamins you are currently taking.
Are you currently under the care of a physician?
- Yes
- No
If "Yes" what is the name of the physician?
Do you...
- Work at a computer for long periods?
- Have more than one pair of eye glasses?
- Want information on thinner, lighter lenses?
- Wear Bifocals?
- If you wear Bifocals are you bothered by head tilting restricted areas of clear vision etc?
- Spend a lot of time outdoors?
- Have prescription sunglasses?
- Have problems with glare or reflection particularly while driving at night?
- Are there times when you'd rather not wear your glasses?
- Have family members in need of eye care?
- Are you diabetic?
Last A1c level
Contact Lenses
Have you ever worn, or are you currently wearing contact lenses?
- Yes
- No
If "Yes" what kind of contact lenses?
- Soft
- RGP
- Hard
- Disposable
- Toric
- Scleral
- Irregular Cornea (Ask me about Keratoconnus and Post Op Corneal Replacement Contacts)
If "No" are you interested in contact Lenses?
- Yes
- No
Are you interested in Laser Refractive Surgery for correction of Nearsighted / Farsighted / Astigmatism?
- Yes
- No
- Ask me about new Contact lenses that are Multifocal for Astigmatism (Contacts that help you read and see far with astigmatism)
COVID-19
Have you or any family member had COVID-19?*
- Yes
- No
Do you have a dry cough?*
- Yes
- No
How long have you had a dry cough and what do you attribute it to?
Do you have a fever?*
- Yes
- No
What is your temperature and how long have you been runing a fever?
Do you experience shortness of breath?*
- Yes
- No
How long have you had shortness of breath?
Digital Retinal Imaging
Bayne Optical now offers digital retinal imaging, a highly advanced screening that photographs the back of the eye.

This evaluation:
- Does not require dilation
- Aids in recognizing health problems such as:
- Glaucoma
- Macular Degeneration
- Hypertension
- Diabetes
- Retinal Detachments
- Optic Nerve Disease (Optic Neuritis)
- Creates an image record that assess the health of your eye from year-to-year
During your examination, either dilation or retinal imaging will be performed.

The Fee for retinal photography is $35.

A discount may be available through your insurance*
Digital Retinal Imaging Consent*
I understand a retinal examination is a required part of the eye health and vision examination. I understand I am offered the alternative to panoramic retinal imaging, which is dilation.
- I accept (to have the photos taken)
- I decline (eye drops will be used for dilation)
Financial Responsibilities
Financial Consent*
Thank you for choosing us for your eye care needs. We are committed to providing you with excellent care and convenient financial arrangements. The following information is regarding your financial responsibilities during this visit and your insurance contributions.
Payments
Payment is due in full at the time of service. We accept Cash, Checks, Visa, Mastercard, Discover, American Express, Care Credit, and Health Savings Card. Fees you may be responsible for include but are not limited to: exam fee, contact lens fitting, copays and deductibles.
Payment for all professional fees are due the DAY of service.

If you miss your scheduled appointment you will be assessed a $40.00 fee.
Insurance
Our office is committed to helping maximize your benefits. Your insurance policy is a contract between you and your insurance company and as an eye care provider, we are not part of that agreement. However, we are always available to answer any questions.
- Your patient portion MUST be paid at the time of service for materials (glasses/contact lenses), deductibles, and copays.
- If you are a contact lens wearer, a contact lens fitting requires a separate exam fee and typically is NOT covered by your insurance.
- Prescription eyeglasses command that all insurance information is collected prior to the placement of your order. There are no exceptions and payment adjustments cannot be made after.
- We can estimate your insurance coverage in good faith, but cannot guarantee coverage due to the complexities of insurance contracts.
- There is a difference between well visit examinations and Medical examinations. We attempt to coordinate all benefits on your behalf when applicable and able.
All sales are final, and because of the prescription nature of these products, no returns can be accepted. You agree to be fully responsible for total payment of services rendered at this office
I understand and agree to this Financial Policy
HIPAA
HIPAA Privacy Consent*
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW CAREFULLY:
I am required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) to provide confidentiality for all medical/mental health records and other individually identifiable health information in my possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made by [BusinessName], and of your individual rights and [Village Optical (DBA) Bayne Optical]'s legal duties with respect to confidential information.
Ways in which I may use and disclose your protected Health information:
I may use and disclose at my discretion your medical records for each of the following purposes only: treatment, payment and health care operations.
- Treatment means providing, coordinating or managing mental health care and related services.
- Payment means activities such as obtaining payment for the mental health care services I provide for you from your insurance or another third party payer.
- Health care operations include the business aspects of running a practice.
I may contact you to provide appointment reminders or other services that may be of interest to you. I will disclose your protected health information to any person you identify that is involved in payment for your care including power of attorney.
I will use and disclose your protected health information when required by federal, state or local law. There are certain situations in which as a therapist I am required by ethical standards to reveal information obtained during therapy to persons or agencies even if you do not give permission. These situations are as follows: (a) If you threaten grave bodily harm or death to yourself or another person, I am required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies; (b) if you report to me your knowledge of physical or sexual abuse of a minor child or of an elder (over 65) or any sexual conduct/contact with a minor, I am required by law to inform the appropriate child welfare or social agency which may then investigate the matter; (c) if I am required by a court of law (court order) to turn over records to the court or if I am ordered to testify regarding those records.
Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until it expires or is revoked. You may revoke authorization in writing a I am required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
By reading this acknowledgement of Receipt of HIPAA Privacy I acknowledge and agree that I understand my operation's use of your information for treatment, payment and health care operations as stated above.
Acknowledgement of Receipt of HIPAA Privacy policies
Privacy Practices'
Notice of Privacy Practices' Consent*
By reading this acknowledgement of Receipt of Notice of Privacy Practices' I acknowledge and agree that I have received a copy of Bayne Village Optical Notice of privacy Practices.

Acknowledgement of Receipt of Notice of Privacy Practices'
Appointment Cancellation / No Show Policy
Appointment Cancellation Policy*
Please note that when you schedule an appointment with us at Bayne Optical, we dedicate time to provide each patient with the quality care they deserve. If you need to cancel or reschedule your appointment, please notify us as soon as possible, no later than 24 hours in advance. Failure to cancel or reschedule at least 24 hours in advance will result in a $40.00 missed appointment fee.
I understand and agree to this Appointment Cancellation Policy

Save and Continue Later

Patient Registration

A Word From Doc Mike From Eye Central About Patient Registration

Patient Registration Form

Patient Information

Account Information

Your Pharmacy

Payment Information

Personal and Family Medical History

Current Medicatons

Contact Lenses

COVID-19

Digital Retinal Imaging

Financial Responsibilities

HIPAA

Privacy Practices'

Appointment Cancellation / No Show Policy