Patient Forms Packet 2022 Logo
  • Thank You For Choosing Fowle Eye Care As Your Vision Provider

  • AS OF 1/1/25: Optomap Retinal Scan and Ocular Coherence Tomography (OCT) will be included as part of your exam. If the tests are not covered by your insurance plan please be prepared to pay the $50 fee for these tests at your appointment.

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  • VISION INSURANCE

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  • MEDICAL INSURANCE

    (for any management of medical/routine care, i.e., diabetes, dry eye, eye infection,glaucoma, etc along with other testing or procedures) will be billed to your medical insurance. All co-pays and deductibles will be patient responsibility.
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  • MEDICAL RELEASE AUTHORIZATION AND INSURANCE ASSIGNMENT:

  • I certify that the information I have provided is true and accurate to the best of my knowledge and authorize the release of any necessary information, including medical information, to my insurance company in order to determine insurance benefits. I understand that my insurance company will be billed for services and/or products and I am responsible for any co-pay, deductible and non-covered or denied charges incurred on my account. Any “quote of benefits” does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations and exclusion of the member’s insurance contract at time of service. If your insurance company determines that a particular service or product is not a covered benefit, they will deny the charge. We suggest you contact your insurance company before your appointment to confirm whether a prior authorization is needed.

                  ****** A NOTE TO ALL OUR CONTACT LENS WEARERS ******

    Contact lenses and any procedures preformed to determine or update contact lens prescriptions are not considered “medically necessary” and may not be covered by insurance, any charge as a result of these procedures will be your responsibility

    ** No Show Policy** - out of respect to others who want to schedule with our Doctors, not showing for a scheduled appointment will incur a charge of $50

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  • Medical and Ocular History Form

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  • Personal Medical History

    Do you have a history of any of the following conditions? Check those that apply.
  • Tobacco Use? If Yes, . .

  • Alcohol Use? If Yes, . .

  • Family History

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  • Should be Empty: