Demographics

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

Address
City:		State: 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 ZipCode:

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Primary Doctor	No Doctor Assigned Dr. Bisen, OD, Rashmi Dr. Gandhi, Tarun	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
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:
Work Phone:

Primary Insurance

Insurance Name:	None AARP Medicare Complete Payor ID: 87726 Aetna AmeriGroup Avesis BCBS Block Vison Care Improvement Plus Conecsus CONECSUS Medicare- Payer ID MR085 MES Vision Metlife/Safegaurd NVA Other Parkland Community Health Spectera Starmount/AwaysCare Superior Vision TriWest Healthcare Alliance UMR Payor ID 39026 United Health Care VSP
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Insurance

Please fill this portion out only if you have an additional insurance card. Otherwise, you can skip to the next tab.

Insurance Name:	None AARP Medicare Complete Payor ID: 87726 Aetna AmeriGroup Avesis BCBS Block Vison Care Improvement Plus Conecsus CONECSUS Medicare- Payer ID MR085 MES Vision Metlife/Safegaurd NVA Other Parkland Community Health Spectera Starmount/AwaysCare Superior Vision TriWest Healthcare Alliance UMR Payor ID 39026 United Health Care VSP
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Review of Ocular System

Have you been told you have any eye conditions?:

(ex. glaucoma, high pressures in the eyes, cataracts, macular degeneration, retinal holes/tears, keratoconus, blindness, any other eye problems)

Eye Medications:

Last Eye Exam:

1 year 2 years 3 years Other

By Doctor:

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA OTC readers Other

Do you have back up glasses?:

No Yes Other

Do you want new glasses?:

Yes No Other

Fill out the section below only if you wear contact lenses:

Type of contacts worn in the past:

Cleaner:

None PureMoist Optifree Clear Care Boston Renu Biotrue Aquify Other

Disposal:

daily 2 weeks monthly weekly yearly Other

Wear Time:

>2 hours today All day Occ. Overnight Extended 8 hours 10 hours 12 hours Overnight Other

Days per week worn:

Hours worn comfortably:

Medications, Allergies, Other History

Prescribed Medications: No meds	Vitamins:

Over the Counter Medications:	Drug Allergies: No Known Drug Allergies

Primary Care Physician:

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years greater than 3 years Other

Reason For Visit:

Check up Annual Specific Other

Name of your Pharmacy:

Pharmacy Address:

Injuries, Surgeries, Hospitalization:

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Yes No Other

Patient Medical History

Do you have a history of any of these conditions?

High Blood Pressure:	Yes	No
Heart Disease:	Yes	No
High Cholesterol:	Yes	No
Asthma:	Yes	No
Headaches:	Yes	No
Arthritis:	Yes	No
MS:	Yes	No
Lupus:	Yes	No
AIDS:	Yes	No
Cancer:	Yes	No
Other:	Yes	No
Diabetes:	Yes	No

Year Diagnosed:

1 yr 2 yrs 3-5 yrs 5-10 yrs 10+ yrs Other

HbA1C:

LBS Reading:

Time:

Family Medical History

Does your family have a history of any of these conditions? Unknown family history

High Blood Pressure:	Yes	No
Heart Disease:	Yes	No
Diabetes:	Yes	No
Cancer:	Yes	No
Glaucoma:	Yes	No
Cataracts:	Yes	No
Macular Degen:	Yes	No
Retinal Problems:	Yes	No
Blindness:	Yes	No
Other:	Yes	No

Social History

Occupation:

Student Police officer Teacher Nurse Salesman Firefighter Engineer Other

Hobbies:

None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

History of STD's?:

None Gonorrhea Syphilis Hepatitis HIV TB Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:

Race:

White Black or African American Asian Patient Declined to Specify American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Other

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Preferred Language:

English French German Spanish Other

Retinal Photo

Terrell Eye Associates is pleased to provide our patients with an advanced digital retinal exam called the CenterVue DRS.

The DRS is a high resolution screening photograph of your retina which will help us document, review, and compare

your retina over time. We will use the DRS exam to document your retinal image for our charts, screen for eye diseases

and improve our ability to view your internal retinal health at a much higher resolution than a slit lamp or ophthalmoscope.

Our doctors are concerned about retinal problems such as macular degeneration, glaucoma, retinal holes, detachments,

and diabetic retinopathy (all of which can lead to partial loss of vision or blindness). Additionally, many symptoms of

systemic diseases such as diabetes, the effects of high blood pressure, and other diseases can be detected with the DRS.

Since insurance will not pay for any retinal imaging unless eye disease is present, the DRS examination is an out of

pocket expense. Our doctors recommend this procedure for all of their patients and will perform the DRS single field

examination at an additional cost of $25 to the basic eye exam you are receiving today.

            Healthy Retina                     Diabetic Retinopathy

Please select one of the following boxes:

I AGREE to have my retinal health evaluated with the CenterVue DRS Exam.
I DO NOT wish to have the Retinal Photographic Exam. I understand that I will still have a thorough eye examination with slit lamp observation.

Submit

By clicking the submit button below, I certify that I have accurately answered the questions provided to the
best of my knowledge. I understand that providing incorrect information can be dangerous to my health. The
information provided will be updated on my medical record at Terrell Eye Associates. I also understand that Terrell
Eye Associates has a hard copy of their HIPAA privacy regulations available at the front desk for all patients that request it.

For Contact Lens Wearers:

The contact lens evaluation and fitting is a separate procedure from the standard comprehensive eye examination
therefore it has a separate fee. Patients that request a prescription for contact lenses will be responsible for payment
of both the comprehensive examination AND the contact lens evaluation fitting. The charges for both fees will
vary based on insurance, if applicable. In order to get your contact lens prescription renewed, you must get a contact
lens fitting every year after your previous prescription expires. The contact lens evaluation fitting includes:

- Contact lens evaluation, which includes measurements of your cornea
- Selection of contact lenses for best visual outcome
- Solution starter kit
- Diagnostic or trial contact lenses, including proper care, insertion and removal training if necessary.
- Appropriate lens changes if needed
- Follow Up visits up to 2 months. (Extra charge after the 2 month period)
- Contact lens prescription


For Vision and Medical Insurance Users:

As a courtesy to our patients, we will file claims with your insurance company. We will do our best to accurately
verify benefits for services and/or materials; however, benefits quoted by your insurance carrier are not a guarantee
of payment. Should your insurance deny a claim for any reason, you will be responsible for any remaining balance
as directed by your insurance. Also, not all services may be covered by your insurance carrier such as screening photos,
refraction, contact lens fittings, frames, and lens addons.

When required by your insurance company, you are directly responsible for obtaining a referral from your Primary Care Physician.

By clicking the submit button below, I certify that I have read and understand the above information to the best of my knowledge.
I authorize and request my insurance company to pay directly to Terrell Eye Associates. I authorize Terrell Eye Associates to release any
information including the records of any examination to third party payors and/or other health practitioners.