Download Eye to Eye Eye to Eye PATIENT FORM

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PATIENT FORM
PATIENT INFORMATION
INSURANCE
Are you a new patient? □ yes □ no
Health Insurance Carrier: __________________________________
Date: __________________
Member ID: ________________________ Group#:_______________
Patient: _____________________________________________________
First
MI
Who is the Primary member? ________________________________
Last
Their birth date: _____________ Their SSN:____________________
Address: ____________________________________________________
Relationship to patient: _____________________________________
____________________________________________________________
City
Gender: □ M
State
□ F
Zip Code
Vision Insurance Carrier: _________________________________
Age ____________ Birth date: _______________
Member ID: ________________________ Group#:_______________
Patient SSN: _________________________________________________
Who is the Primary member? ________________________________
□ Single
Their birth date: _____________ Their SSN:____________________
□ Married
□ Partnered
Employee status: □ Full
□ Part
□ Other: _______________________
□ Unemployed □ Student □ Retired
Relationship to patient: _____________________________________
Employer: ___________________________________________________
OFFICE USE ONLY – DIAGNOSIS CODES
Occupation: __________________________________________________
How were you referred to our clinic? ______________________________
Hobbies/Interests: _____________________________________________
CONTACT INFORMATION
What is the best method of communication for you? Please check any or all. □ Phone □ Email □ Text □ Facebook
Home ______________________________ Work ____________________________ ext. _______ Mobile:________________________________
Email address: __________________________________________________________________________________________________________
EMERGENCY CONTACT Name: __________________________________ Relationship:________________ Number: ______________________
PUPIL DILATION: To Check the Health of Your Eyes
Pupil dilation – Dilation is an important tool in diagnosing certain eye
diseases, especially if you have a history of diabetes, glaucoma,
headaches, high blood pressure, high prescription, migraines, floaters,
flashes of light or family history of eye disease. Dilating eye drops relax the
muscles of the eye and facilitates a more thorough assessment of ocular
health.
It takes about 20-30 minutes, can cause blurry near vision and cause
a sensitivity to light for several hours; however, most patients can
drive home after the dilation.
The doctor strongly recommends that your eyes be dilated at least
every 2 years; there is no additional cost for the procedure.
□ YES, I want to be dilated today.
□ Not today, I will schedule dilation for a later date.
□ NO, I don’t want to be dilated this year
POLICIES
My signature indicates:
1. I have been informed of my rights under the HIPAA Privacy
Policies.
2. I hereby authorize the doctor to release all information
necessary to secure the payment of benefits
3. I authorize the use of this signature on all insurance
submissions.
4. As a potential contact lens (CL) wearer, I have read and
understood the CL Guide and CL professional fees, and I
have been informed that potential risks do exist in wearing
CL.
5. I understand that all fees paid for professional services
are non-refundable and are payable at the time of
service.
6. I accept the policies regarding the purchases of spectacle
lenses, frames, or contact lenses are non-refundable.
7. I understand that I have full financial responsibility for all
charges whether or not paid by my insurance(s).
8. I understand that I will be billed whichever is appropriate
based on the diagnosis from my exam and will be advised in
difference of co-pay.
Signature: ______________________________ Date: __________
Or Legal Guardian (if patient is under 18):
PLEASE CONTINUE TO THE BACK
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PATIENT FORM
HOW CAN WE HELP YOU TODAY? / CHIEF COMPLAINT
EYE HEALTH / SOCIAL HISTORY
Briefly tell us any signs and symptoms you are experiencing.
Last eye exam: ______________ Last physical exam: ______________
□ Distant vision has changed
Do you wear glasses?
□ Intermediate vision has changed
□ All the time
□ Yes
□ Occasionally
□ No
□ Driving
□ Near vision has changed
Do you wear contacts?
□ Get new glasses
Are you wearing contacts at this moment?
□ Out of contacts
□ All the time
□ Contacts are no longer comfortable
□ Yes
□ Reading
□ Computer
□ Yes
□ No
□ No
□ Occasionally
□ I would like to know my contact lens options
Have you undergone any surgeries? ___________________________
□ I would like to know my refractive surgery options
Have you had any eye injuries? _______________________________
□ Other: ______________________________________________
Do you smoke?
____________________________________________________
□ No
Are you pregnant? □ No
□ Yes, ____ packs a day
□ Yes, _____ months
REVIEW OF SYSTEMS
Self
EYES:
Blurred vision
Double vision
Headaches
Squinting
□
□
Eyes feel dry
Halos
OCULAR:
□
Bronchitis
□
Emphysema
NEUROLOGICAL:
Cataracts
Glaucoma
Macular degeneration □
□
□
□
CARDIAC:
□
□
Burning or itching
□
Heart disease
□
Sandy / gritty feeling
□
High blood pressure
Watery eyes
□
Retinal detachment
Red eyes
□
Retinal disease
Mucous discharge
Eye pain
Floaters
Flashes
□
Family
□
□
□
RESPIRATORY:
Asthma
□
Anemia
□
□
□
□
EARS / NOSE / THROAT:
□
□
Chronic cough
Stroke
Sinuses
Headaches
Dry mouth
Migraines
PSYCHIATRIC:
□
□
□
□
□
□
□
□
□
□
Seizures
□
□
Depression
ENDOCRINE:
□
□
Anxiety
OTHER:
Kidney problems
Diabetes
Chest pain
□
Self
Self Family
HEMATOLOGIC:
Light sensitivity
□
□
Eye strain
Self Family
Thyroid Disease
□
□
□
□
Cancer
Type:__________
MUSCULOSKELETAL:
HIV
Arthritis
HEPATITIS
□
□
□
MEDICATIONS
□
ALLERGIES
List medications you are currently taking, including eye drops:
List all of your allergies, including to certain medications:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
CONTACT LENS PATIENTS
If you are interested in wearing CL, whether you are a new or previous CL wearer, a separate CL evaluation must be performed in addition to the
comprehensive eye examination. In addition to determining the CL prescription, a detailed examination of the ocular health is required for those
wearing CL. The CL evaluation is done annually and is required to renew a CL prescription. There is a separate charge for the CL evaluation, and the
actual price is determined by the level of complexity of the CL fitting.
A CL evaluation will include follow-up appointments to determine the fit of the CL and the prescription. These visits are free of charge within 2
months from the initial fitting evaluation. Failure to return the finalized prescription within 2 months of the original examination date will
result in an office visit charge of $30. If longer than 6 months, then a new CL evaluation fee will be charged.
Our private pay fees are:
Contact Lens Evaluation Level One $60 – fitting of non-toric soft contacts, no astigmatism correction
Contact Lens Evaluation Level Two $80 – fitting of toric soft contacts, rigid gas permeable, or bifocal type
Contact Lens Evaluation Level Three $120 – keratoconus fits