Midlothian Eye Care - Appointment Request

Patient's Name*

Email*

Primary Phone (cell preferred)*

You can text me on this number

Best method for us to confirm appointment with you?*

Email

Phone

Text

Preferred Doctor (?) - optional

Dr. Adam Parker

Dr. Megan Parker (W-F only)

Dr. Amanda Lindsey

Encounter Type*

Comprehensive exam (no contacts)

Comprehensive exam + contacts

[Dry Eye Evaluation]

[Med Spa Treatment]

[EYE PROBLEM] (flashing lights, new floaters, eye pain, vision loss, something in your eye, etc)

[TELEMEDICINE] Non-urgent Eye Problems (infections, itchy eyes, stye, etc)

Others

Best Date and Time for you*

How will you be joining teleconference?*

On Laptop or PC that has a webcam

On my smart phone

Please confirm you understand and agree to ALL of the following:*

I agree to the use of video teleconferencing

I understand and agree to allow this encounter to be billed to my medical insurance and if my medical insurance denies the claim, I will be responsible for the full amount of the charges.

Using Vision Insurance?*

No, I have medical insurance only

EyeMed (Blue View Vision)

VSP (Vision Service Plan)

Other (we only accept EyeMed and VSP, so you will have to ask for reimbursement)

EyeMed patients - please read

In order to use your vision insurance for this exam, EyeMed now requires most EyeMed-paying exams to be vision-related only. If you 1) have medical complaints that need to be addressed during your exam 2) significant medical issues arise during your vision exam or 3) you have known medical issues that must be addressed (including but not limited to: diabetes, cataracts, itchy and/or red eyes, dry eyes, glaucoma, retinal neoplasm, etc), your appointment will be billed only to your medical insurance on the day of your visit and a 2nd "vision" appointment will need to be made - OR - you may choose to have both the medical exam and refraction done at the the same visit. If you choose to do both on same day, you will need to pay the refraction fee upfront and consider requesting reimbursement from EyeMed. This is a result of EyeMed's policies - not ours! Other vision insurances such as VSP make it easy for patients with medical issues to have both the medical exam and refraction done on the same day. We recommend you consider this when choosing a new vision insurance.

Exam Choice if Exam is Billed Medically*

Get it all done in 1 appointment: I understand that I will need to pay for the refraction fee upfront and that EyeMed may or may not reimburse me.

2 appointments: I would like to use my EyeMed insurance for the refraction and I understand that I will have to make 2 appointments: 1 for the medical exam and one for the vision check (refraction).

Comments

Office Hours

Appointment Request

Eye Emergency?