These documents are editable PDF forms. Please click the link and you will be able to type responses in the form. On mobile devices, you may have to download the form before it can be edited.
Once completed, please email them to [email protected], fax them to 703-272-7955, or print and bring them to your appointment - if you elect to print and bring the forms in, please notify the office and arrive at least 15 minutes before your scheduled appointment time. Please let us know if you have any difficulties filling out these documents at 703-272-7880.
New Patient Intake Form - Required
This form gives us patient demographics, brief health information, and insurance information.
Insurance Verification, Fees, and Policies Acknowledgement - Required
This form explains our office policies including HIPAA, why we require both medical and vision insurance on file, and fees that may be due at the time of service.
Please send copies of both your medical and vision insurance cards with your completed forms, or you may text a picture of them to 703-272-7880
Retinal Imaging / Optomap Acknowledgement - Optional
This form explains the benefits of retinal imagining (Optomap) and/or dilation and fees that may be associated.
AdaptDx Questionnaire - Optional
The AdaptDx tests how easily your eyes can adjust from light to dark, which can be an indicator of macular degeneration. This is an optional test, and Dr. Nechel and Dr. Butler will discuss if this test is a good option for you at this time.