Existing Patient Form If you are an existing patient, please use the form below. 1Patient Information2Dry Eye Center3Health Testing First Name* Last Name* Date of Birth* Month Day Year Has your address changed?* Yes No Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Has any of your contact information changed (phone/email)?* Yes No Phone*Email* Has your medical insurance changed?* Yes No Medical InsuranceMedical Insurance Provider Medical Insurance Policy Number Medical Insurance Group Number Primary Policy Holder Name Same As Patient Yes, Primary Policy Holder's Name Is Same As Patient Primary Policy Holder's First Name Primary Policy Holder's Last Name HiddenHas your vision insurance changed?* Yes No Vision InsuranceVision Insurance Provider Vision Insurance Policy Number Vision Insurance Group Number Primary Policy Holder Name Same As Patient Yes, Primary Policy Holder's Name Is Same As Patient Primary Policy Holder's First Name Primary Policy Holder's Last Name HiddenAny changes with your employment?* Yes No Employer Billing of Insurances Most people have vision insurance and medical insurance. They are very different in terms of the services they cover and it's important for our patients to understand those differences. Vision coverage (VSP, Eyemed, Spectera, etc.) is mainly designed to determine a prescription for glasses and is not equipped to deal with complex medical conditions and/or diagnosis. It does allow for screening of conditions, but once they are determined, then medical insurance is filed on those services. When a medical condition is present (such as diabetes, cataracts, dry eye, floaters, etc.) it is necessary to file the visit with your major medical carrier (BCBS, Aetna, UHC, Cigna, etc.) and the co-pays, deductible, and co-insurance for that insurance will apply as well as the non-covered service. Insurance carriers set these rules and our office is obligated to follow them. In most cases, there is no way to know prior to the examination which type of insurance our office will be able to file for you. We make every effort to be on every major carrier for your convenience and we will file those claims for you. In the event that we do not take your insurance we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any questions, please let us know. Contact Lens Prescriptions I acknowledge and agree that if I am fit with contact lenses, once the prescription is finalized, I will be provided with a signed copy of my prescription. I consent to receiving either a physical hard copy or electronic email copy of my prescription.Agree to Terms* I have read and agree to the billing of insurancesPatient/Parent or Guardian Signature*Today's Date* MM slash DD slash YYYY Review of Systems*Check all that Apply Constitution (Cancer, Developmental Disabilities, Fatigue) Ear/Nose/Throat (hearing loss, sinus) Neurologic (MS, epilepsy, stroke, autism) Psychiatric (depression, anxiety, ADHD) Cardiovascular (high blood pressure, heart disease) Respiratory (asthma, emphysema, sleep apnea) Gastrointestinal (heartburn, crohn's, ulcers) Genitourinary (kidney disease, prostate, STD, pregnant) Musculoskeletal (arthritis, fibromyalgia, gout) Skin (eczema, rosacea, psoriasis) Endocrine (diabetes, thyroid, hormonal dysfunction) Blood/Lymphatic (anemia, blood disorder) Immune Disorder (allergies, rheumatoid, lupus, sjogren's) None of the above For any checked box, please provide more details:Do you use any EYE medications?* Yes No List any Eye MedicationsDo you use any other medications?* Yes No List all Other MedicationsDo you have any medication allergies?* Yes No List any Allergy MedicationsOther Allergies* Hayfever Ragweed Dust Latex Pets Bees Nuts Shellfish None Any Eye Surgeries, Injuries, or Trauma?* Yes No Please list any Eye Surgeries, Injuries, or TraumaHave you ever been diagnosed with:* Glaucoma Cataracts Keratoconus Macular Degeneration Amblyopia Retinal Tear/Detachment Strabismus (Lazy Eye) None of the above None Do you smoke?* Yes No How much? Do you consume alcohol?* Yes No How much? Immediate Family History*Check all that apply Diabetes Cancer Glaucoma Macular Degeneration High Blood Pressure Other Systemic Retinal Detachment Other Ocular None of the above None Dry Eye CenterDry Eye Disease is a common reason for patients to visit eye doctors. Please take a moment to thoughtfully complete this questionnaire. 1. Report the frequency of your symptoms by checking the appropriate box: 0 = never 1 = sometimes 2 = often 3 = constantDryness, Grittiness, or Scratchiness* 0 1 2 3 Soreness or Irritation* 0 1 2 3 Burning or Watering* 0 1 2 3 Eye Fatigue* 0 1 2 3 2. Report the severity of your symptoms using the rating list below: 0 = No Problems 1 = Tolerable - not perfect, but not uncomfortable 2 = Uncomfortable - irritating, but does not interfere with my day 3 = Bothersome - irritating and interferes with my day 4 = Intolerable - unable to perform daily tasksDryness, Grittiness, or Scratchiness* 0 1 2 3 4 Soreness or Irritation* 0 1 2 3 4 Burning or Watering* 0 1 2 3 4 Eye Fatigue* 0 1 2 3 4 3. Please check if you have experienced the above symptoms Today Within Last 3 days Within past 3 months 4. Do you use eye drops for lubrication?* Yes No How many? 5. Do you have fluctuating vision that improves when you blink?* Never Sometimes Frequently Always 6. Have you been told you have blepharitis?* Yes No 7. Have you been treated for a stye?* Yes No HEALTH TESTING NECESSARY FOR PROPER PATIENT CARE In order to provide PREVENTATIVE eye health evaluations and PRESERVE your sight with EARLY DETECTION of systemic (body) disease and ocular (eye) disease, the following tests must be performed on all patients annually. Your vision insurance does not cover the cost of these vital tests, yet they are necessary for proper eye health examinations. These health tests are being offered to you at a reduced fee as follows: RETINAL PHOTOGRAPHY Taking YEARLY colored photographs of the inside or back of the eye is much like a dentist x-raying your mouth annually. The photos of the retina will document the internal health of the eyes and allow for accurate yearly comparisons. This allows your doctor to detect early eye health changes and can dictate treatment if necessary. iWELLNESS Like an MRI of the eye, the iWellness Exam reveals ocular anatomy and signs of disease in exquisite detail. This breakthrough technology allows your doctor to examine, with unprecedented clarity, structure that is INVISIBLE using traditional methods. This unique technology can help detect potentially vision threatening diseases such as Glaucoma, Macular Degeneration, and others in their earliest stages, thus improving outcomes.The fees for these necessary services are due today and are indicated below.* Yes I choose to have both RETINAL PHOTOGRAPHY AND iWELLNESS performed at a fee of $60. Yes I choose to have RETINAL PHOTOGRAPHY performed at a fee of $30. Yes I choose to have iWELLNESS performed at a fee of $35. No, I choose to decline these health tests. I understand the risk involved with declining. First Name* Last Name* Today's Date* MM slash DD slash YYYY Your E-Signature*PhoneThis field is for validation purposes and should be left unchanged.
