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*Please remember to arrive 15 minutes before your scheduled appointment. Please bring your insurance card(s) and photo ID to your appointment. Patients under age 18 MUST be accompanied by a parent or legal guardian.

*If you are feeling ill, running a fever, or having any serious respiratory symptoms, we kindly ask that you give us a call to reschedule your appointment.

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      Please upload a file

      Review of Systems

      Do you currently, or have you ever had any recurring issues in the following areas?

      Social History


      Individual’s Financial Responsibility

      • I understand that I am financially responsible for my health/vision insurance deductible, coinsurance, or non-covered services.

      • Co-payments are due at the time of service.

      • If my plan requires a referral, I must obtain it before my visit.

      • In the event that my insurance plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of ALL services provided.

      • If I am uninsured, I agree to pay for the medical services rendered at the time of service.

      Insurance Authorization for Assignment of Benefits

      • I hereby authorize and direct payment of my insurance benefits to Corridor Family Eye Care on my behalf for any services provided to me by the office.

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      If signing as Parent/Guardian

      Please read the following:

      During a comprehensive eye exam, our doctors need to evaluate the overall health of your eye. With OptomapⓇ Retinal Exam, we can screen for retinal complications including Macular Degeneration, Glaucoma, and retinal holes or detachments.

      This screening procedure can also detect systemic problems unrelated to the eye that may show signs in the retina such as Diabetes, Hypertension, Cancer/Tumors, autoimmune disorders, and others, earlier than possible with traditional methods.

      The OptomapⓇ Retinal Exam

      • Is as fast as taking a picture.

      • DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, potentially eliminating a 30-minute wait and avoiding side effects such as blurry vision and light sensitivity.

      • Saved in your file, enabling our doctor to make important comparisons during your annual eye exam.

      There will be a $34.00 charge for the OptomapⓇ Retinal Exam.

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      if signing as Parent/Guardian


      Link for HIPAA


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      if signing as Parent/Guardian
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