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Hours & Location
- Our Athens Office
Advanced Services
Eye Care Services
Eyeglasses
Contact Lenses
Our Eye Care Clinic
Insurance

Home » Low Vision Registration Form

Low Vision Registration Form

Name*
Prefix First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Cell Phone
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
(last 4 digits only)
Age*
Occupation
Employer
Race*
- American Indian or Alaska Native
- Asian
- Black or African American
- Hispanic or Latino
- Native Hawaiian
- White
- Declined to Specify
- Other Race
Ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
- Declined to Specify
Language*
- English
- Spanish
- French
- Arabic
Height*
ft/in
Weight*
lbs
How did you hear about us?
- Referral
- Others in Family Have Been in
- Online
- Insurance Provider List
- Other
If someone referred you, please specify who:
If other, please specify:
Date of most recent eye examination
MM slash DD slash YYYY
Doctor who performed your most recent eye examination
City and State of most recent eye examination
Name of Primary Care Physician
Last Exam Date
MM slash DD slash YYYY
Previous Eye Care
Please check all that apply
- Full time glasses
- Eye Surgery
- Eye Medications
- Low Vision Aid/Magnifiers currently used
- Previous Low Vision Evaluation
If eye surgery, please specify the type of surgery:
If eye medications, please list:
If Low Vision Aid/Magnifiers are currently used, please specify:
If Previous Low Vision Evaluation, please specify the date and place:
Please check any of the following that apply to you:
- Double Vision
- Blurred Vision
- Eye Pain or discomfort
- Eye turns in or out
- Hold reading close
- Close, cover one eye
- Eyes frequently red
- Lost place when reading
- Make poor distance judgements
- Eye or health problems in family
- Bothered by light
General Health Problems:
- Past severe head injury
- Thyroid problems
- Diabetes
- High or low blood pressure
- Headaches
- Allergies
- Sinus infections/pressure
- Cataracts
- Glaucoma
Primary Insurance Plan
Name of Insurance
Primary Insured Name
First Last
Relation to Patient
Insured ID Number
Group Plan Name/Number
Secondary Insurance Plan
Name of Insurance
Primary Insured Name
First Last
Relation to Patient
Insured ID Number
Group Plan Name/Number
Please list any additional persons you authorize to access your personal health information (PHI), including billing and medical records information:
Full Name Relationship
Payment is due at the time services are rendered.
I will be paying today by:
- Cash
- Check
- Credit/Debit Card (we accept Visa, Mastercard, American Express)
- Care Credit
If you have insurance coverage for these services or materials and we are current providers, we will submit claims for you. However, we are not liable for collecting your claim. After 30 days, we will expect payment in full from you if your insurance company has not paid.

I hereby authorize my insurance carrier to make payment directly to Five Points Eye Care Center. I authorize that I am financially responsible for all charges whether or not they are covered by insurance or other entities. I also authorize release of any information regarding my treatment or condition in order to obtain payment for services.

I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any services rendered. I have read all the information on this sheet and have completed the above questionnaire. I certify that this information is true and correct to the best of my knowledge. I agree to notify this office of any changes in my insurance status or the above information.
Patient Signature*
Date*
MM slash DD slash YYYY
Parent/Guardian Signature (if minor)
Date
MM slash DD slash YYYY

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Five Points Eye Care

698 S Milledge Ave
Athens, GA 30605

Phone: 706-543-2020
Fax: 706-549-6618
Email: frontoffice@fivepointseyecare.com
(Do not send personal health information by email.)

Monday: 8:00 AM - 5:30 PM
Tuesday: 8:00 AM - 5:30 PM
Wednesday: 8:00 AM - 5:30 PM
Thursday: 8:00 AM - 5:30 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

Hours & Location
Advanced Services
Eye Care Services
Eyeglasses
Contact Lenses
Our Eye Care Clinic
Insurance

Hours & Location
Advanced Services
Eye Care Services
Eyeglasses
Contact Lenses
Our Eye Care Clinic
Insurance

Schedule Appointment

Speak Field

Five Points Eye Care
698 S Milledge Ave
Athens, GA 30605
Phone: 706-543-2020
https://www.fivepointseyecare.com

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