"*" indicates required fields Medical and Vision insurance do not cover all services. These services may include the following: Pupil Dilation - included in exam fee WILL BE PERFORMED AS NECESSARY. Eye drops are used to allow Dr. Ton to exam the retina for holes/tears/abnormalities. The side effects are light sensitivity and decreased ability to focus up close for 4-6 hours.Please InitialYes, I consentNo, I decline Refraction - $60 (covered by vision plans) Needed to determine your prescription for glasses. (MEDICAL INSURANCE DOES NOT COVER REFRACTION) Pre-Test Bundle - $80 (savings of $30) iWellness Exam, Topography and Retinal Photos - Dr. Ton recommends these tests to be performed yearly. Description of tests are below. You can choose to select individual testings and decline the Pre-Test bundle. (NOT COVERED BY INSURANCE) Please InitialYes, I consentNo, I decline iWellness Exam - $40 Recommended for all patients age 12 and older: a quick, non-invasive light scan that allows us to see beneath the surface of your retina. This unique technology can help detect vision threatening diseases in their very early stages when they are most treatable.Please InitialYes, I consentNo, I decline Topography - $30 Recommended for all patients age 12 and older: a non-invasive technique for mapping the surface curvature of the cornea. The cornea is responsibble for 70% of the eye's refractive power so the topography is important in determining the quality of vision and corneal health.Please InitialYes, I consentNo, I decline Retinal Photos - $40 Recommended for patients age 5 and older: photos of the retina, macula, blood vessels and optic nerve (dilation not necessary for most patients).Please InitialYes, I consentNo, I decline Contact Lens Fitting/Evaluation - $75-$800 Applies to all new/returning contact lens wearers. Dr. Ton recognizes that all eyes are different and require different care. Depending on your contact lens requirements, the following services will be provided: contact lens training, lens care kit, trials (if available), and follow up visits to finalize prescription. For patients who require additional correction or specialty lenses such as astigmatism, multifocal, irregular corneas, post surgical corneas or keratoconus, the office will provide a quote that matches each individual's needs. Once Dr. Ton has finalized your prescription, you are eligible to come back within 3 months to make changes without a follow up fee. Contact evaluation/fitting fee is a separate charge from an eye exam and is non- refundable.Please InitialYes, I consentNo, I decline GeneralWHAT IS THE REASON FOR YOUR VISIT TODAY? yearly exam new glasses blurry vision headaches flashes of light dry eyes contact lenses other If other, please explain* ARE YOU INTERESTED IN: computer glasses colored contact lenses prescription sunglasses Latisse® (longer lashes) VuityTM (near focus) Upneeq® (eye lid lift) COMMUNICATION PREFERENCE: Text Telephone Email PhoneEmail Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PAYMENT POLICY(CO) PAYMENTS FOR SERVICES AND MATERIALS ARE DUE AND PAYABLE AT TIME OF SERVICE. The filing of a claim for any services rendered DOES NOT GUARANTEE PAYMENT from your insurance company. You will be financially responsible for unpaid services and materials. We must emphasize that, as a medical care provider, our relationship is with you, not your insurance company. Unaccompanied minors must make payment arrangements prior to the appointment.Please Initial AUTHORIZATION TO RELEASE INFORMATION A copy may be used as an original. I hereby authorize the release of any medical information to my insurance carrier or to a licensed physician concerning my illness and treatment. I also request payment of my insurance benefits to Enhance Eye Care/Dr. Jocelyn Ton.Please Initial HIPPA ACKNOWLEDGEMENTOur Privacy Practice is to not to release any of your information without your written consent. Signing below means that you have received this notice and understand the charges. If you have any questions, please ask the staff to clarify any charges prior to services being rendered. Thank you! Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Patient Name* First Last NameThis field is for validation purposes and should be left unchanged.