Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these eye symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Want Backup Sun Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Recent Flu Immunization

Do you have any of these medical conditions?

Diabetes

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

Does anyone in your family have any of these medical conditions?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Occupation

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Policies

Click here to view HIPPA

Click here to view Contact Lens Policy

Click here to view Insurance and Financial Policy

I have read and acknowledge the above policies.

Signature:

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Date:

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Please list individuals with whom you authorize us to share your medical/financial information.

Name:

Relationship:

Phone#:

Name:

Relationship:

Phone#:

Optomap/Dilated Exam Consent Form
As part of a comprehensive eye examination, it is recommended that ALL patients have the internal health of their eyes thoroughly evaluated every year. This is performed as either a dilated retinal examination or the Optomap retinal imaging.

A thorough retinal exam can detect eye diseases including glaucoma, macular degeneration, retinal detachment, and diabetic retinopathy, as well as risk for conditions such as hypertension, diabetes, and stroke. These health conditions are difficult to detect without the Optomap or dilation of the pupils with eye drops due to the limited view of the internal structures of the eye.

Optomap
No blurred vision
No light sensitivity
Takes 2 minutes to capture photos
Approx 80% of retina viewed
You will review image with the Doctor

Dilation
Blurred near vision for approx. 4 hours
Light sensitivity for approx. 4 hours
Takes 20-30 minutes for drops to take effect
Nearly 100% of retina viewed
Only doctor can view the retina

The Optomap provides an annual, permanent record for your medical file. The ability for our doctors to view last year's image and this year's image side by side for comparison is an invaluable tool in providing comprehensive eye care.

Many patients who choose to have the Optomap will not require pupil dilation, however your doctor will determine if dilation is necessary based on your specific conditions or concerns.

THERE IS AN ADDITIONAL $46 FEE FOR THE OPTOMAP RETINAL EXAM WHICH IS NOT COVERED BY INSURANCE

PLEASE CHOOSE ONE OF THE BELOW:

I have read and understand the above, and agree to the Optomap Retinal Exam ($46)

I have read and understand the above, and agree to pupil dilation (no additional charge)

PATIENT OR LEGALLY AUTHORIZED INDIVIDUAL SIGNATURE

DATE

RELATIONSHIP

Patient information

Billing information

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Medical History

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Eye History

Contact Lens Wearers only:

Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?

Family Eye History

Does anyone in your family have any of these eye conditions?

Review Of Systems

Social History

Policies

I have read and acknowledge the above policies.