Welcome to Our Office



Medical History / Review of Systems:

List any medications you are now taking (including eye drops, birth control pills, vitamins, or over the counter medications):

Do you have or have you ever had any of the following problems:




If patient is 18 or under, please complete:


If yes, please read the following information regarding contact lenses.Wing Eyecare prescribes quality contact lenses to improve your vision and your lifestyle. Contact lenses are FDA regulated medical devices that can cause discomfort, infections, and even permanent vision loss if not cared for properly. New and existing contact lens wearers require additional time and testing during an eye examination to minimize the risk of serious eye problems. This additional testing is only done for contact lens wearers, not for patients who do not wear contact lenses. For this reason, there are additional contact lens evaluation and service fees for new and existing contact lens wearers. Your contact lens evaluation and services fee includes:

1. Specific curvature measurements of the corneas.
2. Evaluation of the current and new lenses to ensure optimal fit, vision and comfort.
3. Medical assessment of the cornea, tear film and conjuctiva as they relate to the contact lens wear.
4. Instructions regarding safe contact lens wear, care and proper cleaning and solutions.
5. Contact lens follow up care for 1 year.

If you have any questions, please do not hesitate to speak with your doctor.

1. Payment for all services and products is the responsibility of the patient.
2. I agree to pay all copays, deductibles, co-insurances and non-covered services as determined by my insurance company.
3. I understand there is a returned check fee applied to every returned check.
4. I agree to pay an additional collection fee for all accounts not paid in the time stated on the final monthly statement.
5. I authorize the release of medical information concerning my illness and treatment by Wing Eyecare to my insurance company.
6. I also authorize the release of my personal medical information to any doctor to whom I may be referred.
7. I understand verification of eligibility is not a guarantee of payment as stated by my insurance company.
8. I authorize payment of my insurance benefits to Wing Eyecare

We will file all insurance forms if Wing Eyecare is a participating provider for your plan.
We will supply you with an itemized statement which you may submit to your insurance carrier.
PAYMENT IN FULL IS REQUIRED AT TIME OF SERVICE

Buy One, Get One FREE!

Buy 1 complete pair of eyeglasses & get a 2nd pair of equal or lesser value FREE!