English Rows Eye Care | Optometrist and Naperville Vision Source provider, Dr. Allan J. Smith

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Convenient Office Hours

Monday 8:00am to 6:00pm
Tuesday 10:00am to 7:00pm
Wednesday 8:00am to 3:00pm
Thursday 10:00am to 7:00pm
Friday 8:00am to 3:00pm
Saturday 8:00am to 12:00pm

24/7 Emergency Care Provided
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Vision Source

Address & Phone Number

3027 English Rows Ave, Ste 209 Naperville, IL 60564

630.922.2661 Phone
630.470.6979 Fax

Se Habla Español
EyeGlass Guide 2.0

Testimonials

There was nothing they could have done to make my visit any better. The staff was great and the Doctor was great with explaining things to me about my eyes and what or how my health problem would do in long term! Great Office!!!!

Robin T.

I am so glad that I returned to Dr. Smith having seen him at a previous practice. I especially liked not having to have my eyes dilated and the thorough unhurried explanation/education of my eye and its components. Thank you!!

Bernadette R.

Returning Patient Information Form

Returning Patient Information Form

Please join us in the effort to reduce the unnecessary waste of paper by filling out these history forms online. Every time this online form is used, it reduces paper waste by approximately 8 to 10 sheets of paper. Also, please read and review the Online HIPAA Privacy Policy, available on our Forms page. You will be required to acknowledge that you have reviewed the HIPAA Privacy Policy before your information can be submitted on the last page of this questionnaire.

Thank you for your efforts.

Filling out the following form now will help make your visit more punctual and thorough. Required areas to be completed are annotated with a red asterisk *

Step 1 of 5

20%
  • Personal Information

  • Please provide us with your full name.
  • Please enter your date of birth
  • Please provide the last four digits of your Social Security Number
    Please indicate your marital status
    Please indicate your sex type.
  • Please provide your home address
  • We only utilize client email information for internal communications to patients. Your information is never shared.
  • Please provide your home or cell phone number
  • Please provide your work phone
  • Please provide your cell/mobile phone number
    Would you like to receive text you reminders?
  • Employer / Student Information

    Please indicate your employment or student status.
  • Please provide your employer name or the name of the school that you are currently attending.
  • Please provide your occupation title or grade level
  • Insurance Information

    Please provide your insurance status for us.
  • Medical Insurance Information

    Please provide your insurance status for us.
  • Vision Insurance Information

  • Policy Holder Information

  • Patient Eye History

  • General Health

  • Pharmacy Information

    Please provide us with your pharmacy name, location, and phone number in the event that we need to contact them regard any prescriptions that need to be ordered on your behalf.
  • Allergies

    Please list any allergies that you may have
  • Contact Lenses / Glasses

  • Meaningful Use

    Meaningful Use is a government program to ensure that healthcare professionals are utilizing their Electronic Medical Records system efficiently to improve healthcare quality and patient safety. English Rows Eye Care understands that this is very personal and sensitive information. We want to ensure you that this information will only be used as part of the Meaningful Use objectives.
  • Authorization

    • I have reviewed the information on this form and it is accurate to the best of my knowledge.  I understand that this information will be used by the Doctor to help determine appropriate treatment.  If there is any change in my medical status, I will inform the Doctor.
    • I authorize my insurance company to pay English Rows Eye Care all insurance benefits otherwise payable to me for services and/or materials.
    • I understand that a quote of eligibility and benefits from my insurance company is not a guarantee of payment.  All benefits are subject to eligibility, medical necessity and the terms, conditions, limitations and exclusions of my health benefit plan at the time services are rendered and that I am financially responsible for all co-pays, co-insurance and non-covered charges.
    • I authorize the use of this signature on all insurance submissions.
    • I authorize English Rows Eye Care to release all information necessary to secure the payment of benefits.
    • I acknowledge that I was offered/provided a copy of English Rows Eye Care’s Notice of Privacy Practices.
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