Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Cell Phone:
SSN:		Email:
Birthday:
Sex:	Male Female	Marital Status:	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Reason for Visit

Reason for Today's Visit: (annual exam, contact lens exam, office visit)

Annual Exam

Contact Lens Exam

Office Visit

Other:

Other Problems or Concerns:

Diabetic Exam

Failed School Screening

Failed DPS Vision Exam

Other:

Occupation:

Date of Last Eye Exam:

1 year 2 years 3 years never years ago cannot remember Other

By Whom?

Drug Allergies:

Primary Care Physician:
Last Well Exam?	1 week 1 month 3 months 6 months 1 year 2 years Other
Last Doctor's Visit/Reason	Annual Check up Illness well check Follow up on physical Other

Systemic Medications:

Eye Medications	Over The Counter Medications:	Vitamins:

PATIENT OCULAR HISTORY: (injuries, infections, Surgeries, Diseases )

None	Eye Infection	Eye Injury	Cataracts	Cataract Surgery
Strabismus Surgery	Amblyopia (Lazy Eye)	Macula Degeneration	Glaucoma	Refractive Surgery (LASIK, PRK, RK)

Other:

FAMILY OCULAR HISTORY: (Glaucoma, Retinal detachment, Macula degeneration, Crossed / Lazy Eyes, Blindness, Cataracts, Other Eye Disease)

None	Cataracts	Glaucoma	Retinal Detachment
Macula Degeneration	Amblyopia (Lazy Eye)	Diabetic Retinopathy	Blindness

Other:

PATIENT MEDICAL HISTORY: (HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid)

None	Arthritis	Diabetes Type 1	Diabetes Type 2
GI Problems	Headaches	Heart Conditions	HIV+
Hyperlipidemia (High Cholesterol)	Hypertension (High Blood Pressure)	Respiratory Disease	Thyroid Disease

Other:

FAMILY MEDICAL HISTORY: (None, Adopted, Diabetes, Cardiovascular disease, Hypertension, Cancer, Kidney disease)

None

Adopted

Diabetes

Cardiovascular Disease

Hypertension

Cancer

Kidney Disease

Other:

Injuries, Surgeries, Hospitalization:

Pregnant Or Nursing

No Yes Unsure Other

RoS and Social History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Review of Systems

CONSTITUTIONAL: Fatigue, Weight loss/gain, fever, chills, night sweats	None Fatigue Weight loss/gain Fever Chills Night Sweats Other
OCULAR: Sudden Blurred vision, Dischage, dryness, Flashes/floaters , Loss of vision, pain	None Sudden Blurred Vision Discharge Dryness Flashes/Floaters Loss of Vision Pain Other
EAR, NOSE, THROAT: Runny Nose, Ear aches, Hearing changes, Vertigo, Sore throat	None Runny Nose Earaches Hearing Changes/loss/ringing Vertigo Sore Throat Other
CARDIOVASCULAR: Chest pain, Palpitations, Swelling of feet, Pain with walking	None Chest Pain Palpitations Swelling of Feet Pain with Walking Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GASTROINTESTINAL: Abdominal pain, Difficulty swallowing, Change in bowel habits	None Abdominal pain Difficulty swallowing Change in bowel habits Other
MUSCULAR/SKELETAL: Joint pain/stiffness, swelling, reness/warmth, cramps	None Joint pain/stiffness Joint swelling Joint redness/warmth Cramps Other
INTEGUMENTARY: Rash, Hair loss, Itching, Pigmented lesions	None Rash Hair loss Itching Pigmented lesions Other
NEUROLOGICAL: Muscle weakness, Memory loss, Numbness, Tingling	None Muscle weakness Memory loss Numbness Tingling Other
PSYCHIATRIC: Anxiety, Depression, Hallucinations, Nervousness	None Anxiety Depression Hallucinations Nervousness Other
ENDOCRINE: Heat/Cold intolerance, Excessive hunger, Excessive Thirst, Excessive urination	None Heat/cold intolerance Excessive hunger Excessive thirst Excessive urination Other
ALLERGIC / IMMUNOLOGIC: Swollen Lymph Nodes, Itching/Hives, Hay Fever, Sneezing	None Swllen lymph nodes Itching/hives Hay fever Sneezing Other
OTHER SYMPTOMS:

Social History

Do you Smoke?	No Yes Other	If yes, how many packs per day?	None 1/2 pack 1 pack 2 packs 3+ packs Other	And for how many years?
Do you drink?	No Yes Occasionally Socially Other	If yes, how many drinks per day?	1 per wk 1 per/day 2 per/day 3+ per/day occasionally socially Other
Do you use recreational drugs?	No Yes Other
Do you have any STDs?	None Other

COVID Screening

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition	Yes	No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact
With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact
With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis,
Or Have You Been Asked To Quarantine?

Exams Consent

OPTOMAP RETINAL IMAGING

Optomap retinal imaging captures 200° images of the retina without the side effects of dilation drops. Optomap is non-invasive and thoroughly evaluates for retinal holes or detachments, ocular health changes related to high cholesterol or high blood pressure, diabetic retinopathy and other diseases which may lead to vision loss. Optomap is part of all routine eye exams at an additional fee of $39. Medical insurance may cover this test depending on your policy and/or existing medical conditions. For some eye conditions, such as floaters or flashes of light, a dilated examination is still required. Dilation increases the in-office time by approximately 20 minutes and its side effects include blurred vision and sensitivity to light.

iWELLNESS SCAN

Do you or your family have glaucoma or macular degeneration? Do you have diabetes with vision changes?
Our iWellness scan takes a 3D image of the optic nerve and retina, similar to an ultrasound. It is a quick, painless scan that provides early detection, monitoring and treatment of eye diseases including glaucoma, macular degeneration, and diabetic retinopathy. This test is recommended for patients over 50 or patients with family history of glaucoma or macular degeneration. The fee for iWellness scan is $25.

• Yes I do want to have iWellness scan done today. .
• No, I do not want to have iWellness scan done at this time. I do not hold Brilliant Eye Care and its employees liable for eye diseases which could have been detected by the iWellness scan.

VISUAL FIELD TESTING CONSENT FORM

Have you had a stroke? Do you or a family member have glaucoma? Is peripheral vision important for your job?
A visual field test checks for loss of sight or missing areas of vision, both centrally and peripherally. Visual field testing allows us to map the health of the nerve pathway and may aid in early detection in glaucoma, as well as detecting and monitoring damage from neurological conditions such as strokes. This is a non-invasive test that takes approximately 5 minutes for an additional fee of $15. Medical insurance may cover this test depending on your policy and/or existing medical conditions.

• Yes, I do want to have a visual field screening today.
• No, I do not want to have a visual field screening at this time. I do not hold Brilliant Eye Care and its employees liable for eye diseases which could have been detected by the visual field screening.

Policy Consent and Submit Data

I understand that in accordance with the FCLCA and FTC regulations, my prescription, once finalized, will be made available in electronic format for me to access at my convenience in the patient portal and that this constitutes my acknowledgement of receipt of my prescription. I understand and agree to all statements made herein and understand that my signature will be collected digitally after all forms have been accepted.

NOTICE OF PRIVACY PRACTICES

Right to Notice
As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accountability Act (HIPAA), Brilliant Eye Care can use your protected health information for treatment, payment and health care operations. a) Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. b) Payment - We may use and disclose your health information to obtain payment for services we provide you. c) Health care operations - We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competency or qualifications of healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization

Most uses and disclosures that do not fall under treatment, payment, health care operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time.

Emergency Situations

In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person's involvement in your healthcare.

Marketing

We will not use your health information for marketing communications without your written authorization.

Required by Law

We may also use or disclose your health information when we are required to do so by law.

Abuse or Neglect

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your or other people's health or safety.

National Security

We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information of inmates or patients to the appropriate authorities under certain circumstances.

Appointment Reminders

We may use or disclose your health information to provide you with appointment reminders via phone, e-mail or letter.

Your Rights as a Patient

You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations. You have the right to receive confidential communications regarding your protected health information. You have the right to inspect and copy your protected health information. You have the right to amend your protected health information. You have the right to receive an account of disclosures of your protected health information. You have the right to a paper copy of this notice of privacy practices.

Legal Requirements

Brilliant Eye Care is required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are posted to this site, or are available within our office.

Complaints

If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office. You will not be retaliated against in any manner for a complaint.

Contact Information

For further information about Brilliant Eye Care's privacy policies, please contact Thuong Le, OD at the following email address or phone number: brillianteyecare@gmail.com/(979) 695-3937.

INSURANCE & PAYMENT POLICY

Insurance may cover none or only part of your fees. If we do not accept direct payment from your insurance plan, you will be required to pay our office at the time of service and submit your receipt for reimbursement from your insurance company. If your insurance does not pay as expected, you are ultimately responsible for all charges. We are not responsible if you are not eligible for benefits. We will be happy to assist you with your claims.

The doctor strongly recommends that ALL our patients receive the visual field testing and dilation as part of our comprehensive and diagnostic evaluation of your eyes and health, although they are NOT required to obtain a prescription for glasses or contact lenses. Please initial Yes or No below.

Please check, sign and date that you have read, understand, and agree to the above, then click the submit data button to complete your online form registration. Thank you!

Check: Patient Signature: Date: