Patient Forms

NEW PATIENTS

Please download, complete, and print the following 5 documents.
Bring these with you to your appointment. 
 

Patient Registration

General Consent to Treat

Refraction Notification

Assignment of Benefits

Medical History Questionnaire

HIPAA*
*Please read this form, but you do not need to bring it with you


 

ADDITIONAL FORMS

If records from another facility need to be released to our office, 
please complete and print the following forms: 
 

Medical Record Release

Permission to Discuss Medical History

 


Office Policies

Appointments

Routine appointments are scheduled by calling our main number at 703-997-9710. Early morning and evening appointments are available. We are also available for emergencies and treatments both during and after business hours. A $50.00 fee will be charged for any appointment canceled without 24 hour notice.
 

ITEMS TO BRING WITH YOU

  • Insurance Card 
  • Photo Identification
  • Any eyeglasses
  • A list of prescription medications
  • Contact lenses prescription 
    or information printed on your contact lens packaging
  • Forms as required (see above)

Refraction

Refraction is the testing to determine the prescription that you need for glasses.

Your insurance company may not cover this part of the examination. The cost of refraction is $62.00.


Confidentiality

Your records are kept strictly confidential. If another individual or organization needs access to information about you, we will require your authorization before any information is released.


Insurance 

Any required copayment will be collected at the time of service. Most insurances will cover complete eye examinations and treatments if there is a medical condition or a diagnosis.

Insurance companies may or may not cover routine eye examinations without a medical diagnosis. Please check with your insurance carrier. Our billing department is happy to assist you.