Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone:
Cell Phone:
SSN: Email:
Birthday:
Sex: Male Female Marital Status:

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: By Whom?



Drug Allergies:
Primary Care Physician:
Last Well Exam?
Last Doctor's Visit/Reason

Systemic Medications:

Eye MedicationsOver 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



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
OCULAR: Sudden Blurred vision, Dischage, dryness, Flashes/floaters , Loss of vision, pain
EAR, NOSE, THROAT: Runny Nose, Ear aches, Hearing changes, Vertigo, Sore throat
CARDIOVASCULAR: Chest pain, Palpitations, Swelling of feet, Pain with walking
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GASTROINTESTINAL: Abdominal pain, Difficulty swallowing, Change in bowel habits
MUSCULAR/SKELETAL: Joint pain/stiffness, swelling, reness/warmth, cramps
INTEGUMENTARY: Rash, Hair loss, Itching, Pigmented lesions
NEUROLOGICAL: Muscle weakness, Memory loss, Numbness, Tingling
PSYCHIATRIC: Anxiety, Depression, Hallucinations, Nervousness
ENDOCRINE: Heat/Cold intolerance, Excessive hunger, Excessive Thirst, Excessive urination
ALLERGIC / IMMUNOLOGIC: Swollen Lymph Nodes, Itching/Hives, Hay Fever, Sneezing
OTHER SYMPTOMS:

Social History
Do you Smoke? If yes, how many packs per day? And for how many years?
Do you drink? If yes, how many drinks per day?
Do you use recreational drugs?
Do you have any STDs?


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

DILATION OF THE EYE

When the eyes are dilated, the doctor is able to get a broader view of the inside of the eyes. If you are experiencing any floaters or flashes of light, a dilated examination is required to determine the cause. Dilation is recommended for all patients regardless of age. The side effects of dilation include blurred vision at near (approximately 4-6 hours or longer) and sensitivity to light. The distance vision may also be blurred in some individuals. There is no additional charge for the dilation.

The side effects of dilation include blurred vision at near (approximately 4-6 hours) and sensitivity to light. The distance vision may also be blurred in some individuals.
  • Yes, I do want to have my eyes dilated today for no additional fee. I have been advised to be cautious with activities while my eyes are dilated and avoid driving if my distance vision is affected.
  • No, I do not want to have my eyes dilated at this time. I am aware of the consequence of not being dilated, and I do not hold Brilliant Eye Care and its employees liable for eye diseases which could have been detected by dilation.
  • No, I do not want to have my eyes dilated at this time. I will return at a later date for the dilation. I am aware that at this later visit, I will also be charged an office visit fee in addition to the dilation fee.
RETINAL IMAGING

Hate getting Dilated? We can save you time and blurred vision with the Optomap Daytona, a ultra-widefield retinal imaging system that uses the newest scanning laser technology to provide a high resolution 200 degree view without the side effects of dilation drops. Optomap imaging can help detect abnormalities in the eye that can lead to blindness and takes less than a minute to capture. It is highly recommended for all since it is a permanent record used to compare for potential retinal changes. The fee for the Optomap image is only $35. Medical insurance may cover this test depending on your policy and/or diagnosis.
  • Yes, I do want to have retinal imaging done today for an additional fee of $35.
  • No, I do not want to have retinal imaging done at this time. I do not hold Brilliant Eye Care and its employees liable for eye diseases which could have been detected by retinal imaging.
VISUAL FIELD TESTING CONSENT FORM

A visual field analyzer checks for loss of sight or missing areas of vision, both centrally and peripherally. It is possible to map the health of the nerve pathway by this method. Visual field testing can assist us in the detection of glaucoma, retinal problems (such as diabetic retinopathy, tears, holes, and detachments) and some neurological diseases. This is a non-invasive, painless test that takes approximately 5 minutes for an additional fee of $15. Medical insurance may cover this test depending on your policy and/or diagnosis.

This is a non-invasive, painless test that takes approximately 5 minutes.
  • 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.
iWELLNESS SCAN

The Topcon Maestro OCT camera gives a 3D image of the retina. It is a quick, painless, and comprehensive scan used for early detection, monitoring, and treatment of eye diseases such as Diabetes, Glaucoma, Macular Degeneration, and Retinal Detachments. Since these diseases tend to progress without any symptoms in the early stages and can lead to blindness, the iWellness scan is highly recommended for all patients. The fee for the wellness scan is $25. Medical insurance may cover this test depending on your policy and/or diagnosis.

  • Yes, i do want to have iWellness scan done today.
  • No, i do not want to have iWellness scandone 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.


Policy Consent and Submit Data


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: