Patient Forms

To make your initial appointment more efficient, we ask that all new patients please complete all patient forms in advance. Please click the link below and follow the instructions to print out the new patient forms, fill out the information requested, and bring with you to your first appointment.

New Patient Paperwork (English)

New Patient Paperwork (Spanish)

 

Medical Records Request

Medical Records Request


Late Cancellation/ No Show Policy

Thank you for trusting your eye care to Avery Eye Clinic. When you schedule an appointment with Avery Eye Clinic, we strive to provide you with the highest quality care. Should you need to cancel or rescheduled an appointment please contact our office as soon as possible, but no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who are waiting for an appointment.

The Late Cancellation/No Show Policy is as follows:

  • Any patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24-hour notice will be considered a No Show and charged a $25.00 fee.
  • Any established patient who fails to show or cancels/reschedules an appointment with no 24-hour notice a second time may be charged a $50.00 fee.
  • A new patient who fails to show or cancels/reschedules an appointment with no 24 hour notice a second time may not be rescheduled with that doctor, at the doctor’s discretion.
  • If a third No Show or cancellation/reschedule with no 24-hour notice should occur, the patient may be dismissed as a patient of Avery Eye Clinic.
  • The fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next office visit.
  • As a courtesy, and when time allows, we make reminder calls, text messages, and emails for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect. We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you feel there are extenuating circumstances, please contact our Front Office Supervisor, to discuss the No Show fee. You may contact Avery Eye Clinic 24 hours a day, 7 days a week during business hours. Should it be after business hours or a weekend, you may leave a message.

Service Animal Policy

Avery Eye Clinic is committed to making reasonable modifications in policies, practices, and procedures to permit the use of service animals by persons with disabilities. Service animals play an important role in ensuring the independence of people with disabilities, and it is therefore our policy to welcome into our facility any animal that is individually trained to assist a person with a disability. Avery Eye Clinic also takes very seriously its obligation to all patients to provide a sterile and uncontaminated environment that minimizes the risk of infection. In order to balance the above stated goals, Avery Eye Clinic adopts this policy.

What is a Service Animal?

Service animals include any dog or other therapy animal that is individually trained to do work or perform tasks for individuals with disabilities, including physical, sensory, psychiatric, intellectual, or other mental disability. Service animals do not always have a harness, a sign, or a symbol indicating that they are service animals. A service animal is not a pet. Service animals assist people with disabilities in many ways, such as:

  • Guiding people who are blind or have low vision and retrieving dropped objects for them;
  • Alerting people who are deaf or hard of hearing to sounds and the presence of others;
  • Carrying and picking up items, opening doors, or flipping switches for people with disabilities who have limited use of hands or arms, limited use of their legs, or limited ability to bend or stoop; Pulling wheelchairs;
  • Alerting people with disabilities to the onset of medical conditions such as low or high blood sugar, seizures, protecting them and cushioning them if they fall, reviving them, and performing other tasks that reduce the risk of disability-related injury;
  • Doing work or performing tasks for persons with traumatic brain injury, intellectual disabilities, or psychiatric disabilities, such as reminding a person with depression to take medication or waking him/her up, alerting a person with anxiety to the onset of panic attacks, orienting people with schizophrenia to reality, and helping people with intellectual or cognitive disabilities to locate misplaced items, find places, or follow daily routines;
  • Providing physical support and assisting people with physical disabilities with stability and balance.

Requirements Regarding Service Animals

  • Patients with service animals are encouraged to bring their animals to the facility and introduce them to the staff.
  • Patients with service animals are encouraged to bring a spouse, friend, companion, or significant other along with them whenever they bring a service animal to the facility.
  • When a patient brings a service animal to the facility, the service animal must be harnessed, leashed or tethered, unless these devices interfere with the service animal’s work or the individual’s disability prevents using these devices. In any event, the service animal must be under control.
  • Service animals will be allowed to be present in the lobby waiting area.
  • In order to protect from a break in sterility that could lead to infection or contamination, once a patient is called in past the lobby waiting area and into the examination or procedure rooms, the service animal may not follow or accompany the patient into the examination or procedure rooms.
  • The service animal will stay in the lobby area under the control of the spouse, friend, companion, or significant other that accompanied the patient.
  • If the patient was not accompanied by a spouse, friend, companion, or significant other, the service animal will stay in the lobby area with a staff member.
  • When a patient brings in a service animal, the staff will be encouraged to minimize the amount of time that the patient is separated from the service animal. Most of the time, people with disabilities who use service animals may be easily identified without any need for questioning. If we can tell by looking, it is our policy not to make an individual feel unwelcome by asking questions. If we are unsure whether an animal meets the definition of a service animal, it is our policy to ask the individual only two questions:
    1. Is the service animal required because of a disability?
    2. What work or task has the service animal been trained to perform?

If the individual says yes to the first question and explains the work or tasks that the animal is trained to perform, we will welcome the person and service animal into the facility without asking any additional questions about his or her service animal. We will not ask the individual questions about his or her disability. We will not ask the individual to show a license, certification, or special ID card as proof of their animal’s training. We will not ask an individual to use a specific entrance or exit to the facility.

Avery Eye Clinic has the right to exclude a service animal from its business if the animal is out of control and the handler does not take effective action to control it, or the animal is not housebroken. We will not exclude a particular service animal based on past experience with other animals or based on fear unrelated to an individual service animal’s actual behavior. Each situation will be considered individually. When there is a legitimate reason to ask that a service animal be removed, staff must offer the person with the disability the opportunity to receive services without the animal’s presence.