Forms
Medical History Questionnaire
Patient Registration
REFERRALS Some insurance plan guidelines require a referral when seeing a specialist. If your plan requires this, please be sure to have a valid referral prior to coming for your appointment. If you do not have a valid referral at the time of your appointment, it may be necessary to reschedule.
PATIENTS OF MAUMEE EYE CLINIC
We are using a new computer software program called "E-Prescribing" that allows us to send your prescription for your eye drops through the computer system to your pharmacy or mail order company.
We must have a list of all medications you are taking to put on your account in the system. This will help identify any contraindications to something we may prescribe to you. Specifically, we need the name of the actual medication you are on, even if it is a generic, how often you take it, and the dosage. For example:
Lipitor, 20 mg, once a day
Thank you for your assistamce in this matter. We try to stay on top of new technology to help serve you better! We appreciate your business and your referrals.
Financial Information
LASIK FEES AND METHODS OF PAYMENT
Please call 419-893-4883 for current LASIK pricing
Fee for LASIK surgery includes:
- 2-Hour Pre-operative Evaluation
- Corneal Topography
- Wavescan Wavefront™ diagnostic testing and mapping
- Surgeon Fee
- Facility Fee
- Post-Op Medication Kit
- Enhancement Surgery — if necessary
- All post-operative care — for one year
- Lifetime Commitment Policy
Methods of Payment Accepted:
- Certified or Cashier's Check
- Money Order
- Cash
- Mastercard, Visa, Discover, and American Express
Financing is available — convenient monthly payments. 90-days same as cash always available and periodic special financing terms may be an option.
As a service to our patients, we are pleased to be affiliated with CareCredit®, the nation's leading patient payment plan. With CareCredit® you can finance 100 percent of your procedure, and there are no up-front costs, no annual fees, and no pre-payment penalties. With CareCredit®, you can begin your LASIK vision correction today at Maumee Eye Clinic, near Toledo, Ohio. Convenient low monthly payments can also be arranged with CareCredit®.
With the popular 90 Days Same as Cash plan, there are no interest charges if you pay your balance in full within the specified time period. Monthly payments can be as low as 3 percent of your balance.
For procedure fees from $1,500 to $25,000, there is an Extended Payment Plan that offers one of the lowest monthly payments available. This plan is recommended for patients who would prefer more time to pay. Apply online at www.CareCredit.com or call 1-800-365-8295.
Chase Health Advance is another option for financing your LASIK surgery at Maumee Eye Clinic. Chase also offers our patients no down payment and no interest loans. With Chase you can apply online at www.chasehealthadvance.com or call 1-800-510-5638. Then call our office to schedule your procedure.
If you live, work, worship or attend school in Lucas, Wood or Fulton counties and you prefer to keep your financing local, call Directions Credit Union and ask about their "Lifestyle Loans". With Directions you can apply online at www.directionscu.org or call 419-720-4785. Directions Credit Union is a non-profit financial cooperative which has served the Toledo area for over fifty years.
Your safety, comfort, and convenience are our top priorities. We provide outstanding care, and we are dedicated to helping patients achieve a new visual clarity. Embrace the benefits of LASIK vision correction today at Maumee Eye Clinic and start enjoying an exciting, active lifestyle.