Philadelphia Lasik
First Appointment Form

To save yourself some time in our office, please fill out the following form and then hit the submit button at the bottom of the page. This will e-mail a copy of this form to Siepser Laser Eyecare and open a printable copy for you to sign and date. To download a Microsoft Word™ version of this form click here.

Patient Information

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To the best of my knowledge all information supplied is accurate and true to date.
Patient Signature_____________________________________ Date:____________

Past Medical History and Review of Systems

Please check if you have had problems with or are presently complaining of any of the following:

Family History

Has any member of your family (including parents, grandparents, and siblings) ever had the following? Approx. Age When

Please List and Supply the Dates of:

When Was Your Last:

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I declare all the information true and correct to the best of my knowledge.

Signature________________________ Date:_________________

FINANCIAL POLICY

If your insurance covers refractive surgery:

In the rare case that your insurance reimburses for refractive surgery, we will follow all the necessary guidelines required for payment. However, this is not a guarantee of payment. Any amount that is not covered, applied to a deductible, or is due for a co-payment, will be your responsibility. If your insurance requires a specific form, please provide one to our office.

Additional Testing:

There is no charge for the normal refractive evaluation and your insurance will not be billed. However, any patient that requires additional testing outside of the normal scope of the refractive evaluation (including, but not limited to visual field tests, epithelial cell count, or monitoring intraocular pressures, or any other additional testing prompted by a diagnosis unrelated to the refractive evaluation, etc.) these are additional services and will be billed to your insurance or become your financial responsibility. If you have an insurance plan that requires you to have a referral for any of these additional tests, it is your responsibility to obtain and bring a referral to your appointment. If you do not have a referral that covers your visit, we will have to reschedule your appointment. Please remember that your insurance company issues these regulations.

General:

We will bill your insurance carrier as a courtesy to you. However, you are responsible for the payment of your account. If you do not have insurance coverage and require any of the above mentioned additional testing, you are required to pay for services the day they are rendered. As a convenience to our patients, we accept MasterCard and VISA payments.

I request that payment of authorized Medicare, private insurance, or any other health plan benefits be made to me or on my behalf for any services furnished by the doctors at Siepser Laser Eyecare, including physician services. I authorize any holder of medical or other information about me to release any information needed to determine these benefits for related services to the Health Care Financing Administration and its agents.

I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY OF THE OFFICE OF SIEPSER LASER EYECARE.

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X____________________________________* TODAY'S DATE ____________

Name (printed): __________________________________________

*Your signature is required to proceed with your evaluation.