Online Forms

For Your Visit

You should wear/bring all eyeglasses and contact lens to your visit as well as a list of all prescription and over the counter medications you currently take. All comprehensive eye exams dilation. If you are uncomfortable driving after having your eyes dilated, bring a driver with you.

Patients must adhere to any safety precautions in place, please see COVID-19 Policy for current guidelines.

Patients are encouraged to arrive promptly to all scheduled appointments. We understand that you may need to cancel or reschedule your appointment. If you need to cancel an appointment, please call at least 24 hours in advance to reschedule. Appointments that are cancelled with less than 24 hours notice are a “no show,” and are subject to a $40 cancellation fee.

Thank you for your confidence in our office, we look forward to assisting you with all your eye care needs.


At Family Eye Care of the Carolinas, 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.
  • 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.

New Patient Health History Form – Required

Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals you have regarding your eye health or vision on the form.

Download & Print Form

Registration

You must REVIEW your entries and then click SUBMIT in order for them to be saved. Keep your confirmation number for reference to any problems.

Registration

Established patients should complete registration information every year to ensure we have your most current contact and insurance information as well as any health changes you have experienced. If you have not been seen in our office since 2018, you are advised to submit your information.

What you need to know about appointments

Patient Portal


Patient Forms

Forms for additional needs are provided below. If you need paper forms mailed to you please request them when making your appointment. If you have any questions, please do not hesitate to contact us.

HIPAA Policy of Family Eye Care of the Carolinas

HIPAA Privacy Act

Print and complete the following forms as needed:

Financial Policy and HIPPA Policy – when financial responsibility changes or additional people need to be added to HIPPA permissions

Adult Strabismus and Diplopia Referral Form – must be completed for any adult patient to be seen in our specialty clinic for eye muscle/alignment issues or double vision

Release of Medical Records – to send or request transfer of medical records

Refraction Waiver – if your medical policy does not cover refractions (FECC does not participate with vision plans)

Spanish Forms

Spanish Welcome Letter

Spanish – Financial and HIPPA policy

Spanish – Medical History – Children/Minors

This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.



Family Eye Care of the Carolinas complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Family Eye Care of the Carolinas does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Family Eye Care of the Carolinas:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact our office manager.

If you believe that Family Eye Care of the Carolinas has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: FECC Office Manager and Civil Rights Coordinator, 1902 N. Sandhills Blvd., Aberdeen, NC 28315, 910-692-2020, fax 800-308-9356, [email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

 

 
To view Non-Discrimination Act in other languages

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Locations

Find us on the map

Hours of Operation

Our Regular Schedule

Monday:

8:00 am-5:00 pm

Tuesday:

8:00 am-5:00 pm

Wednesday:

8:00 am-5:00 pm

Thursday:

8:00 am-5:00 pm

Friday:

8:00 am-5:00 pm

Saturday:

Closed

Sunday:

Closed