VISUAL HISTORY Briefly describe the main reason for having an examination:
Blurred Vision Distance Blurred Vision Near Blurred Vision Distance/Near Headache Pain Watery Itch Redness Location:
OU - Both Eyes
OD - Right Eye
OS - Left Eye Duration:
Several Years
1 Day
2 Days
3 Days
1 Week
1 Month
3-6 Months
>1 Year
Recent
Long-standing Severity:
Mild
Moderate
Severe
Debilitating
Improved Timing:
Constant
Seasonal
Intermittent
Weekly
Monthly
Evenings
Mornings Context:
Computer
Outside Modifying factors:
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?
Yes
No If yes, what is the due/birth date?
Any other condition?
Do you have?
Hepatitis
HIV
Sexually Transmitted Diseases
PRIMARY CARE PHYSICIAN Primary Care Physician's Name:
Last Visit Date:
HEALTH HISTORY Allergies/Alerts:
Do you have any other symptoms related to this?
None
Dizzy
Headache
Loss of Vision
Blurred vision
Other
General Health History:
Other eye issues or problems:
EYE HISTORY 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?
Never
Occasionally
Daily Other
How often do
you consume alcohol:
Never
Occasionally
Daily Other
Occupation:
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:
Optomap Form
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
without dilation , 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.
Yes
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.
Please Read:
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.
Patient Signature:
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
Practices Form
Patient Signature:
I agree to receive a copy of my prescription digitally.
You're Done! Please hit the Submit button below.