New Patient Form (English)

First Name*

Last Name*

Middle Initial*




Social Security #



Zip Code


Phone Number*




Date of Birth


Date of last eye exam

Reason for visit

How were you referred to our office

List of any medications you currently take (prescription and over the counter)

Are you allergic to any medications?

If Yes, list the medications

List all major illness (glaucoma, diabetes, high blood pressure, heart attack, etc. or injuries (concussion, etc.)

List any surgeries you have had (cataract, appendectomy)

Do you currently have any problems in the following fields? If YES, please circle or add additional information.

EYES: Poor vision, eye pain, tearing, redness, etc.

If yes, write here:

PSYCHIATRIC: anxiety, depression, insomnia

If yes, write here:

ENDOCRINE: diabetes, hypothyroid, etc.

If yes, write here:

MUSCLES, BONES, JOINTS: joint pain, stiffness, swelling, cramps, arthritis, etc.

If yes, write here:

GASTROINTESTINAL: upset stomach, diarrhea, constipation, hernia, ulcers, etc.

If yes, write here:

RESPIRATORY: congestions, wheezing, short of breath, etc.

If yes, write here:

NEUROLOGICAL: numbness, headache, seizures, paralysis, etc.

If yes, write here:

FEMALES: are you pregnant? nursing?

If yes, write here:

CARDIOVASCULAR: high BP, racing pulse, etc.

If yes, write here:

SKIN: pimple, warts, growths, rash, etc.

If yes, write here:

BLOOD/LYMPH: bleeding, cholesterolemia, anemia, problems related to blood transfusion, etc.

If yes, write here:

ALLERGIC/IMMUNOLOGY: sneezing, swelling, redness, itching, hives, lupus, etc.

If yes, write here:

GENITAL, KIDNEY, BLADDER: painful urination, frequent urination, impotence, yellow jaundice, etc.

If yes, write here:

EARS, NOSE, THROAT: hard of hearing, stuffy nose, earache, cough, dry mouth, etc.

If yes, write here:

FAMILY HISTORY (Mother, Father, Grandparents, Siblings):

Has any member of your family had these diseases? (Check all that apply)

Other heritable disease:


Does your vision limit any activities of daily living (driving, reading, sports, work, etc.)?

Are you interested in Lasik?

Have you ever had a blood transfusion?

Do you drink alcohol?

If YES, how much?

Do you smoke?

If YES, how much?

How many years?


Insurance Provider:

Insured Name:

Insured Date of Birth:

Group #:

Insurance ID #:

Relationship to Patient:

Financial & Insurance Policy:

Thank you for choosing Southwest Orlando Eye Care as your Vision Care Provider. As a part of our services, we try to contain the ever-rising cost of vision care. In an effort to do so, we advise you to read and sign the following financial policy prior to treatment. Patient or responsible party must complete our information and insurance form before seeing Dr. John Nowell.

  • FULL PAYMENT, CO-PAYMENT, PERCENTAGES AND/OR DEDUCTIBLES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept cash, checks, Visa, MasterCard, American Express, Discover. and Checks. If you are purchasing eye glasses or contacts, you will be expected to pay in full before any orders can be processed.

  • No Show Policy: A patient is considered "NO SHOW". If an appointment is missed or cancelled with less than 24 hours notice. Failure to give 24 hours notice will result in a $100 fee.

  • Office Policy: Insurance is billed as a courtesy to our patients; however, the patient is the final responsible party. If your insurance has not paid within 60 days, you will be notified. Returns or cancellations are made at the discretion of the office manager.

  • Minor Patients (under the after of 18): The adult accompanying a minor (patient/guardian) is responsible for full payment at the time of service. For unaccompanied minors, payment arrangements need to be made in ADVANCE and we must have parents or guardians written permission prior to treatment of a minor.

  • Returned Checks: A $50.00 service charge will be applied to your account for returned checks. All returned checks will not be redeposited. All balances must be paid in cash or by credit card. One attempt will be made to collect this debt from the patient, if not collected within 5 days of the returned check; the account will be turned over to our collection agency. We request a copy of your driver's license for your records if you wish to make payments by check.

  • Spectacle Prescription: If the patient desires to take their spectacle lens prescription elsewhere, Southwest Orlando Eye Care will not be responsible for any warranty on glasses made elsewhere. However, the optician will be happy to check the prescription of your glasses against your prescription given at no charge. If you are not happy with your eyeglasses. Frames come with a one year warranty.

  • Contact Lens Patients: Additional time and testing is required for the fitting and evaluation for contact lenses so there will be an additional professional fee charged outside of the comprehensive examination fee. Patients have 90 days of follow-up care from the date of the fitting to make any changes in the prescription necessary, any visit after 90 days, a fee will be incurred. A contact lens prescription is only valid one year from the exam date and cannot be filled once expired. Once contacts have been ordered and received by the patient, contact lenses cannot be returned. If the patient desires to take their contact lens prescription elsewhere, Southwest Orlando Eye Care will not be responsible for any warranty on their contact lenses, and all follow-up visits will be charged an additional professional fee.

  • Eyeglass and contact lens prescriptions (when requested) are faxed at the end of each business day.

Please acknowledge that:

1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party in that contract.

2. You are responsible for all charges that are denied/not covered by the insurance company. Not all services are covered under.

3. Although we verify coverage through your insurance company with each and every patient, verification of benefits is not a guarantee of payment. You must present a company of your insurance card for your records if insurance or any discount plans are being utilize. Only one insurance/discount plan is accepted, per patient, per year.

Patient Responsibility Agreement: (Please check one)

  • I authorize release of any information concerning my healthcare and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I hereby authorize payment of insurance benefits directly to the Optometrist, otherwise payable to me.

  • I have read and understood the above. (Please sign below)



Notice of Privacy Practice

This notice describes how your health informaiton may be used and disclosed. Please review it carefully.

1. At Southwest Orlando Eye Care, we have always kept your health information secure and confident.

2. A law requires us to continue maintaining your privacy, to give you this notice, and to follow the terms of this notice.

3. The law permits us to use or disclose your health information to those involved in your treatment. For example a review of your file by a specialist doctor whom we may involve in your care.

4. We may use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company.

5. We may use or disclose your health information for our normal healthcare operations. For example, one of your staff will enter your information into our computer.

6. We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the call.

7. In an emergency, we may disclose your health information to a family member or another person responsible for your care.

8. We may release some or all of your health information when required by law.

9. You may request in writing that we not use or disclose your health information as described above.

10. As we will need to contact you from time to time, we will use whatever address, telephone numbers, or email address we have on file.

11. You have the right to transfer copies of your health information to another practice.

12. You have the right to see and receive a copy of your health information, with a few exceptions. Give us a written request or sign a records request form in regards to the information you are requesting.

13. If we change the details of this notice, we will notify you of the changes in writing.

14. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, D.C. 20201.

15. However, before filing a complaint, or for more information or assistance regarding you health information privacy, please contact our office at 407-270-2217.


I have received a copy of the Southwest Orlando Eye Care Notice of Privacy Practices. Returns or cancellations of glasses or contacts are made at the discretion of this office. An in office credit will be issued. Progressive lenses have a non-adapt 90 day warranty, which means we can exchange the lenses for single vision or lined bifocal lenses. Ophthalmic lenses for glasses are custom made for you.

Print Name


If signing as a parent or guardian, please print the name of the patient below:

Retinal Imaging

Digital Retinography System (DRS): The DRS captures a digital image of the retina, the portion of the eye responsible for seeing. Since every patient’s eyes are unique, this image provides a baseline for comparison as the doctor monitors your eye health through the years.

Having this done yearly allows the doctor to know exactly when and how your eyes are changing and if further treatment is needed. It is completed in a matter of seconds and provides instant results that will be reviewed with you today!

iWellness Optical Coherence Tomography (OCT): The iWellness OCT is the newest technology in retinal imaging. It uses near infrared light to capture a 3D image of retina, allowing the doctor to access a portion of the eye impossible to evaluate using standard examination techniques.

This advanced test detects ocular diseases such as glaucoma, macular degeneration, or diabetic retinopathy before they would be visible during a routine eye exam. As with most conditions, early detection is key in properly treating eye disease. The results are instantaneous and will be reviewed with you today!

To help us provide a higher quality of care to our patients we recommend these tests to all patients. In most cases, these advanced tools are not covered by insurance. * If you elect to do only one of these tests, our doctors prefer that you select the DRS imaging.

Contact Lens Evaluation

Annual contact lens evaluations are not included in a routine eye exam and may not be covered by insurance. Payment will be required at the time of service for all contact lens evaluations. The fee for the annual evaluation is based on the complexity and type. The usual and customary fee range is $95 to $160. All contact lens progress exams will be covered without charge for 90 days. Additional fees may apply.


No Show Policy

Due to the high volume of no shows in the office, we have made some recent changes to our standard policies.

This policy has been updated to be fair to the patients that are in need of an appointment and cannot be seen due to an already booked schedule. Our goal is to provide quality eye care in a timely manner. No shows and late cancellations inconvenience those individuals who need access to timely medical care. This policy enables us to better utilize available appointments for our patients in need of eye care.

Appointment confirmations are done the day before an appointment via text message, email, and/or a phone call from a staff member. This allows for us to reach all patients by at least one means of communication. If a patient is unable to keep the appointment or must reschedule, we need to be given notice 24 hours prior to the office visit. Failure to give this notice or to be present at the time of the scheduled appointment without a call cancelling, will result in a $50 no show fee added to your account. This fee will be the responsibility of the patient, not the insurance company.

We understand that special unavoidable circumstances may cause you to cancel within 24 hours and in such instances, we will waive the fee upon management approval.

I have read and understand the NO SHOW POLICY listed above.

Patient/Parent/Guardian Name:

Staff Witness:


rats3898 none 8:00 AM -4:00 PM 8:00 AM -7:00 PM 8:00 AM -7:00 PM 8:00 AM -7:00 PM 8:00 AM -4:00 PM 8:00 AM -1:00 PM Closed optometrist # # #