Download Established Patient Form

WELCOME TO AGAVE EYE CARE, PLLC
Mr./Mrs./Ms. ______________________________________________________ Birth Date ____________ Age _________
LAST
FIRST
Any change in address, phone #, e-mail or insurance?
MI
PREFERRED
Yes___ No___
Please Note Changes Here:
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INFORMATION RELEASE CONSENT: I AUTHORIZE ANY HOLDER OF MEDICAL/OPTICAL INFORMATION TO RELEASE
INFORMATION ABOUT ME TO AGAVE EYE CARE AND I AUTHORIZE AGAVE EYE CARE TO RELEASE MEDICAL/ OPTICAL
INFORMATION ABOUT ME TO OTHER HEALTH CARE PROVIDERS, ATTORNEYS, OR INSURANCE COMPANIES.
SIGNATURE ___________________________________________________________
DATE ______________________
NAME OF PARENT OR LEGAL GUARDIAN (if patient is under 18 year old) _________________________________________
ALL PATIENTS ARE RESPONSIBLE FOR PAYMENT AT THE TIME OF SERVICE.
PATIENT FINANCIAL RESPONSIBILITY
I HEREBY AUTHORIZE AGAVE EYE CARE, PLLC TO APPLY FOR BENEFITS ON MY BEHALF FOR COVERED SERVICES
RENDERED BY THEM. I ALSO ASSIGN MY BENEFITS AND REQUEST THAT ALL PAYMENTS FROM MY VISION INSURANCE
BE MADE DIRECTLY TO AGAVE EYE CARE, PLLC. I AGREE TO ASSUME RESPONSIBILITY FOR FULL PAYMENT PENDING
ANY REMAINING BALANCE THAT IS NOT COVERED BY MY INSURANCE COMPANY.
SIGNATURE ________________________________________________ DATE _______________________
REASONS FOR TODAY’S VISIT
___ Want new glasses
___ Lost / Broke Glasses
___ Want new contact lenses
___ Try contact lenses (clear OR colored)
___ Try bifocal contact lenses
___ Having trouble seeing
(Please Circle:
distance
OR
near
OR
both
OR
@ the computer)
___ Other please explain:
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DO YOU EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS?
___ Blurred vision
___ Discharge
___ Double vision
___ Flashes; How often? __________
___ Burning / Stinging
___ Itching
___ Loss of vision
___ Floaters; How often __________
___ Dryness / Sandy / Gritty
___ Pain / Soreness
___ Light sensitive
___ Other ___________________
___ Redness
___ Eye fatigue
___ Excessive tearing / watering
___ Headaches:
Where?
Frontal /
temporal /
back of head
When?
Early morning / afternoon / evening / weekdays / weekends / after school / after work
How often?
Daily /
_____ times per week /
Do you feel eye strain or soreness at the end of your workday?
_____ times per month
Yes___
No___
EYEWEAR HISTORY:
Are you seeing well with the glasses that were prescribed to you last year?
Yes___
No___
N/A ___
If no, please explain:
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How do the contact lenses ( prescribed on the last visit) feel at the end of the day (10 - 12 hours) ?
_________________________________________________________________________________________
Any change in personal or family medical and/or ocular History?
Yes___
No___
Please Note Changes Here:
Any eye infection, injury, or surgery since the last visit?
Yes___
No___
Any new allergy to medication and/or new medications?
Yes___
No___
DIGITAL RETINAL IMAGING CONSENT
We have incorporated a highly sophisticated computerized Digital Retinal Imaging Camera into our practice to be used as part of your
yearly comprehensive eye exam. Whether you are a young or a WISE person, this type of imaging can help us establish a base line data
which can be used to compare to subsequent images to monitor for changes on your optic nerve, blood vessels, macula and the retina.
This imaging is highly sensitive at detecting “early” or “subtle” signs of diseases such as macular degeneration, glaucoma (degenerative
optic nerve condition), changes due to diabetes, and high blood pressure, or thinning of the retinal tissue.
It is especially important for those patients who suffer from macular degeneration, glaucoma, diabetic retinopathy, or retinal condition
or have family members who suffer from these conditions.
Normal Young Retina
This process takes 3 to 5 minutes and can be done dilated or undilated. There is a
$25 FEE. INSURANCE DOES NOT
COVER THIS PROCEDURE.
____
I ACCEPT
____
I DECLINE
TESTING OF YOUR FIELD OF VISION
The “20/20” measurement which we are all familiar with refers to only ONE component of your vision; your visual acuity. Having 20/20
vision does not mean that your Field of Vision is normal. Many people with 20/20 vision have an abnormal Field of Vision but are not
aware of any vision problems. Diseases that can cause an abnormal Field of Vision WITHOUT affecting visual acuity include glaucoma,
brain tumor, aneurysms, optic nerve diseases and retinal diseases. Physical examination of your eyes does NOT allow the doctor to
determine if your Field of Vision is normal. Since early detection often results in better outcomes, testing your Field of Vision using a
computerized analyzer is recommended. Please indicate below if you wish to have computerized screening of your Field of Vision
performed.
_____ YES
(There is an additional $10.00 fee for this service.)
_____ NO
(If you decline; only a rudimentary method of testing your Field of Vision will be performed).
*$30 FOR BOTH PROCEDURES ABOVE*
SIGNATURE
________________________________ DATE
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DILATION
The purpose of dilation is to evaluate the health of your eyes on the inside, back part of your eyes, particularly
the parts of retina that cannot be observed when your pupils are small. IT IS ESSEINTIALLY A PHYSICAL
EXAM OF YOUR EYES. Eye drops will be instilled into your eyes that will enlarge your pupils.
THERE IS NO EXTRA CHARGE FOR DILATION !
YOU SHOULD EXPECT:
•
Sensitive to sunlight. Disposable sunglasses will be provided if necessary.
•
Blurry vision for a period of 4 to 6 hours, particularly up close. The effect will wear off in ~ 6 hours. However,
some patients experience the effects for a longer period of time (especially people with lighter eye colors).
•
Difficulty driving home. However, you should be able to drive home reasonably if you are familiar with the streets
and landmarks in your neighborhood.
I have been informed on this date of the need for a dilated examination of my eyes. The purpose and
side effects of dilation have been explained to me.
_____
I ACCEPT.
_____
I DEFER TO LATER DATE (WILL RESCHEDULE AT MY CONVENIENCE).
_____
I DECLINE THIS YEAR.
SIGNATURE
________________________________ DATE
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