Briefly describe the main reason for having an examination:
Blurred Vision Distance Blurred Vision Near Blurred Vision Distance/Near Headache Pain Watery Itch Redness
OU - Both Eyes
OD - Right Eye
OS - Left Eye
Correction Improves Vision
Cold Compress Helps
Warm Compress Helps
Oral Pain Reliever Helps
Topical Medicine Helps
Associated: Do you have any other symptoms related to this?
Other eye issues or problems:
CORRECTIVE LENS HISTORY MEDICAL HISTORY / REVIEW OF SYSTEMS
List all medications you are currently taking (including any OTC/vitamins):
List any medications you are allergic to:
Are you pregnant or nursing?
No If yes, what is the due/birth date?
Any other condition?
Do you have?
Sexually Transmitted Diseases
PRIMARY CARE PHYSICIAN
Primary Care Physician's Name:
Last Visit Date:
Do you have any other symptoms related to this?
Loss of Vision
General Health History:
Other eye issues or problems:
Do you have a history of any of the following? Are you currently experiencing any of the following?
How often do you smoke/use tobacco products?
How often do
you consume alcohol:
Who can we thank for referring you to our office?
If not referred, how did you hear about Cherry Hills Family Eyecare?
Family Member Insurance List Coworker Friend Doctor Internet Drove By COVID - 19 Patient Waiver
Valued patient: Our office is committed to providing quality eye care with
friendly personal service in as safe an environment as we can reasonably
provide. In order to help protect you from COVID-19 exposure, we have
taken measures such as using additional Personal Protective Equipment,
taking extra disinfecting steps, screening patients, controlling patient flow
and allowing extra time for procedures. All of these will help to minimize
exposure to the virus. However, NO facility of any kind, including this one,
can guarantee that you will not encounter the COVID-19 (Coronavirus).
Therefore your acceptance of the concurrent risk involved and that you will
hold harmless Cherry Hills Family Eye Care, its doctors and staff, suppliers,
vendors and all other persons associated directly or indirectly with this eye
care facility in the event that you believe you contract or are even exposed
to the virus here.
Please Check That You Accept The Above Agreement:
As part of each comprehensive eye examination, our doctors would like all patients to have a digital image of the retina with the scanning digital imaging system. The retinal scan allows evaluation for many eye diseases such as macular degeneration, glaucoma, retinal holes, retinal detachments, diabetic retinopathy, tumors, and many more diseases
, for most patients.
Early detection is crucial!
The additional cost of this evaluation is $35.00.
The Optomap (digital image of the retina) will be performed as part of every comprehensive examination UNLESS the test is declined by the patient.
Insurance Notification Welcome to Cherry Hills Family Eye Care. Thank you for choosing us for your eye care needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please take a moment to complete the following information. Any information we already have on file will appear on this form. If you have any questions, please do not hesitate to ask.
In order to control the cost of billing, we ask that the patient's portion is paid at the time services are rendered unless other arrangements are made in advance. We would rather control billing costs than be forced to raise our fees. All professional services and material are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge on all returned checks.
Payment from my insurance is to be paid directly to Cherry Hills Family Eye Care. I understand that will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.
Privacy Practices Notice
Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.
Notice of Privacy
Practices View Notice of Privacy
I agree to receive a copy of my prescription digitally.
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