Thank you for choosing Pediatric Ophthalmology & the Center for Adult Strabismus. We look forward to participating in your care. Please read the following details in full to prepare for your upcoming appointment. Prior to your appointment, we would ask that you take a moment to complete a few forms and bring them to your appointment. 

Pediatric Forms

If the patient is under the age of 18, please complete the forms below. Please note that you can type directly into the forms inside your web browser.

• Minor Patient Registration – 2024 PDF
• Acknowledgment of Privacy Practices
• Communication Consent – 2020 (PDF)
• *Read Our Privacy Practices 

Adult Forms

If the patient is over the age of 18, please complete the forms below. Please note that you can type directly into the forms inside your web browser.

• Adult Patient Registration – 2024 PDF
• Policy and Procedures
• Acknowledgment of Privacy Practices
• *Read Our Privacy Practices 

Other Forms

If directed by office staff, please bring these completed forms to your appointment:

• Medical Records Release Form – 2017 (PDF)
• Minor Treatment Consent Form – 2020 (PDF)
• Adult Approved Contacts – 2020 (PDF)
• Communication Consent – 2020 (PDF)

If you have any questions about whether you should complete and bring these forms to your appointment, feel free to contact us.

Additional Information

• Please bring these completed forms with you to the appointment. Please do not mail them ahead of time.
• Please bring your insurance card and driver’s license to every appointment.
• Without an insurance card, we cannot file with your insurance company.
• HMO, EPO, POS and any other managed care plans must have a valid referral prior to appointment. Contact your insurance carrier if you have further questions about referrals.
• We are not contracted and cannot file claims for vision plans. We will provide a detailed receipt for you to file with your vision plan if necessary.
• All examination self-payment fees, co-payments, deductibles, and co-insurance fees will be collected at the time of service. We accept cash, check, MasterCard, Visa, and Discover. You will receive a detailed receipt after your visit.

Consent to Treat a Minor Child

• A biological parent or legal guardian must be present at the initial office visit and be present for the entire visit for any patient under the age of 18. Legal guardians MUST provide legal paperwork and have photo identification. After the initial visit, a grandparent or other caregiver may accompany the minor child with a Minor Treatment Consent Form signed by the parent or legal guardian prior to the visit.

 
Food and drinks are not permitted in the waiting room and examination rooms. We respectfully request that ADULTS AND CHILDREN COMPLY WITH THIS POLICY. This includes, but is not limited to coffee, crackers, cereal, candy, cookies, and sodas.

Children & contact lenses: A contact lens prescription is not the same as an eyeglass prescription. A contact lens prescription includes the power of the lens, corneal curvature, diameter of the lens, lens thickness, material of the lens, water contact, and brand. The physicians of this practice do not write contact lens prescriptions. Our physicians will do a comprehensive eye examination on your child and will provide you with an eyeglass prescription if one is required. If your child is interested in contact lenses we can refer you to a contact lens specialist for a fitting.

Reminder calls are executed 1-3 days prior to your appointment by the automated system TeleVox®. On rare occasions, you may not receive a reminder call. In this event, you are still responsible for keeping or canceling the appointment. Informing us of changes to your phone number (& address) assists us in our effort to reach you.

Cancellations of appointments should be made at least 24 hours in advance of the scheduled appointment. Appointments may last up to 2 hours. Please plan your schedule accordingly. Appointments canceled without 24 hours notice will be charged $50. 

Late arrival of appointments: if you are more than fifteen minutes late for your appointment, you may be asked to reschedule. Because we understand your time is valuable we do our best to keep our schedule running on time. Please arrive promptly to ensure this courtesy to everyone.

Refraction is the process of determining the eye’s need for corrective lenses, or the eye’s refractive error. Dilation of the pupil may or may not be required to perform this procedure. Refraction is often necessary for determining a medical diagnosis. Dilation typically occurs no more than one time a year.

A Medical Records Release Form is required to release medical records, including eyeglass prescriptions, to you or any other person, school, employer, business, or government agency. If you need to obtain your records, please print the above-mentioned form, complete it and send it to the office where you receive your care. It may take up to 14 business days for your records to be sent. Incomplete or illegible forms will delay or prevent the release of medical records.