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Download Patient Forms

At Friedrichs Family Eye Center, PC, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.

  • You will need AdobeReader® to download and complete the forms. Click here to download.
  • Download the required form(s). Print out the form(s) and complete the required information.
  • Fax your printed and completed form(s) to our office or bring them with you to your appointment.
Registration Form - PDF

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Online Registration Form

Please be prepared to sign this document upon arrival at the office. Thank you.

INSURANCE: Please present your insurance ID at each visit, it is the responsibility of the patient to make accurate and detailed insurance information available to us to enable processing of his or her insurance claim. The patient is to be considered self-pay until this information is provided to us.

All co-payments and non-covered services are due at the time of service. Self-pay patients are responsible for payment in full at the time of services.

REFERRALS/AUTHORIZATIONS: It is the responsibility of the patient to obtain a referral from his or her primary care
physician prior to the scheduled visit if a referral is required. If a referral is not obtained, the patient accepts full
financial responsibility for all services rendered.

Insurance Authorization for Assignment of Benefits – I hereby authorize and direct payment of medical benefits to Friedrichs Family Eye Center on my behalf for any services furnished to me by its providers.

Vision and Medical Coverage - There are two types of insurance benefits that will pay for services and products. You may have both and our practice may accept both. Vision care plans only cover well visits, may have a co-pay and allow discounts on materials. They DO NOT cover diagnosis, management or treatment of eye disease, eye allergies or eye injuries. In the event that you have any eye health problems or a systemic health problem that has ocular (eye) complications, your medical insurance will be utilized for the services provided.

Authorization to Release Records – I hereby authorize Friedrichs Family Eye Center to release to my insurer,
governmental agencies, or any other entity financially responsible for my medical care, all information, including
diagnosis and the records for any treatment or examination rendered to me needed to substantiate payment for such
medical services as well as information required for precertification, authorization or referral to other medical provider.

I acknowledge that I was offered a copy of the Notice of Privacy Practices for this office.

Please select
Please select

Please do not submit any Protected Health Information (PHI).


Wellness Image
A new, highly sophisticated computerized instrument now allows us to provide you with a more thorough medical
analysis of the eyes. The digital retinal imaging system takes images of the back of the eye. This procedure assists the
doctor in the early detection of many disorders, including glaucoma, diabetic retinopathy, macular degeneration, retinal
detachments and other vision threatening conditions. The images will be stored in the computer and compared with
the images from future exams. This allows the doctor to observe even the smallest amount of change from the previous exam.

The doctor strongly recommends that all patients have this procedure performed. It is especially important for people who have: Headaches, See Spots or flashes, has a family history of diabetes, glaucoma or high blood pressure, or who have high cholesterol or have reached the age of 40. All new patients should have this test for their records.

There is an additional fee of $30.00 and is due at the time of service. If a diagnosis is made as a result of this procedure, medical insurance will cover the cost of the initial photo and additional photos needed for photo documentation analysis.


Location

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Hours of Operaton

Our Regular Schedule

Martinsville Hours

Monday:

8:30 am-5:30 pm

Tuesday:

8:30 am-6:00 pm

Wednesday:

8:30 am-5:30 pm

Thursday:

8:30 am-5:30 pm

Friday:

8:30 am-5:30 pm

Saturday:

Hours Available

Sunday:

Closed

Chatham Hours

Monday:

8:30 am-5:00 pm

Tuesday:

8:30 am-6:30 pm

Wednesday:

8:30 am-5:00 pm

Thursday:

8:30 am-5:00 pm

Friday:

8:30 am-5:00 pm

Saturday:

Closed

Sunday:

Closed

Danville Hours

Monday:

8:30 am-5:30 pm

Tuesday:

8:30 am-5:30 pm

Wednesday:

8:30 am-5:30 pm

Thursday:

8:30 am-5:30 pm

Friday:

8:30 am-5:30 pm

Saturday:

Closed

Sunday:

Closed