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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
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Ms.
Dr.
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Address:
City:
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Domestic partner
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Employer / School Name
Primary Doctor
No Doctor Assigned
Dr. Beaty OD, Melissa
Dr. Follow ups, Walk Ins
Dr. Wang OD, Lawrence
Misc/Guardian
Primary Care Doctor
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:
Vision Insurance 1
Insurance Information
Insurance Name:
None
New Insurance
A2
ABMS
Advantica
Adventist Risk Management
ae
Aetna
Aetna
Alaska ELectrical Health & Welfare Fund
Altius
Ameriben
Ameritas
Anthem Vision
Armada Collections
Assurant Health
Avesis
Bankers Life & Casualty
BC/BS
BC/BS Federal Employees
Beech Street Corp.
Benefit Administrators
Benefit Planners
Benicorp
Brimhall
Capitol Administrators
Caremore
CDS Group Health
Cement & Concrete Workers
Champva
Chemical Lime Co.-Apex Plant
Chesterfield Resources Inc
Cigna
Cigna International
Clark County Self Funded
Clearwater Paper Corporation
Clovis
Coast Benefits
Coresource
Coventry
Crystal PM
Culinary
Custom Building Products
Cypress Benefit
dall
Davis
Definity
Electrical Workers
Eye Associates of Nevada
Eye care Associates
Eyeconic
Eyemed
First Health
Fiserv Health
Fiserv Health (Benefit Planners)
GE Financial
Geha
General Atomics
Gilsbar
Golden Rule
Great West
Green Flag Collections
Group Dental Insurance Plan
Group Resources
Guardian
Health Market Insurance Company
Health Partners
Health Plan of Nevada
Health Scope
Health Smart
HMA
HMA INC
Horseshoe (Binions)
Humana
IMX
Insurance discount plan
Jacobson MSO, Inc.
JAS INC.
John Alden
Lions Club
Loomis
Lumenos
Madison National
Mail Handlers
Major League Baseball
Medben
Medical Eye Services
Medical Mutual
Medicare
Mediversal
Meritain Health
Misc. 1
Misc. 2
Moda Health
Mutual of Omaha
National Automatic Sprinkler Industry
Nevada Care
New Eyes
New West Medicare
No Insurance
Operating Engineers
Opticare Of Utah
Other
P5 Health Services
Pabco Gypsum
Painters Trust
PBA
PEN Medicare Claims
Percs/Boyd Gaming
PHCS
philadelphia American Life Ins Comp
Pinnacle
Pipeline Industry Fund
Plumber and Pipefitters
Prime Silver State
Principal Financial
Priority Health
Prominence Health First
Providence Health
Regence
Reno Air
Security Life
Security Lilfe
Senior Dimensions
Sentinel
Sierra Health Medical
SIerrea Nevada Spectrum
Silver State Medical
South Point Benefits
Southwest Carpenters Health and Welfare
Spectera
State Farm Medicare Supplement
Station Casinos
Sterling Options
Summerlin Life & Health
Superior Vision
Teachers Health Trust
Teamsters Montana
Teamsters Security Fund
The Loomis Company
Tricare
True BLue
Twin City Optical
U.S. Safety
UHC Military services
UMR
United American Insurance
United Brotherhood of Carpenters
United Health Care
Universal Health Care
Universal Health Network
UPRR Health Services
Vision Benefits of America
Vision Care Advantage
Vision One(Discount Only)
Vision Service Plan (VSP)
Wellish
Wellish Co-Manage
Wells Fargo Third Party Admin.
Wisconsin Electrical Health & Welfare
WMI/TPA
Workers Comp-Liberty Mutual Insurance Company
Insurance Plan:
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:
Vision Insurance 2
Insurance Information
Insurance Name:
None
New Insurance
A2
ABMS
Advantica
Adventist Risk Management
ae
Aetna
Aetna
Alaska ELectrical Health & Welfare Fund
Altius
Ameriben
Ameritas
Anthem Vision
Armada Collections
Assurant Health
Avesis
Bankers Life & Casualty
BC/BS
BC/BS Federal Employees
Beech Street Corp.
Benefit Administrators
Benefit Planners
Benicorp
Brimhall
Capitol Administrators
Caremore
CDS Group Health
Cement & Concrete Workers
Champva
Chemical Lime Co.-Apex Plant
Chesterfield Resources Inc
Cigna
Cigna International
Clark County Self Funded
Clearwater Paper Corporation
Clovis
Coast Benefits
Coresource
Coventry
Crystal PM
Culinary
Custom Building Products
Cypress Benefit
dall
Davis
Definity
Electrical Workers
Eye Associates of Nevada
Eye care Associates
Eyeconic
Eyemed
First Health
Fiserv Health
Fiserv Health (Benefit Planners)
GE Financial
Geha
General Atomics
Gilsbar
Golden Rule
Great West
Green Flag Collections
Group Dental Insurance Plan
Group Resources
Guardian
Health Market Insurance Company
Health Partners
Health Plan of Nevada
Health Scope
Health Smart
HMA
HMA INC
Horseshoe (Binions)
Humana
IMX
Insurance discount plan
Jacobson MSO, Inc.
JAS INC.
John Alden
Lions Club
Loomis
Lumenos
Madison National
Mail Handlers
Major League Baseball
Medben
Medical Eye Services
Medical Mutual
Medicare
Mediversal
Meritain Health
Misc. 1
Misc. 2
Moda Health
Mutual of Omaha
National Automatic Sprinkler Industry
Nevada Care
New Eyes
New West Medicare
No Insurance
Operating Engineers
Opticare Of Utah
Other
P5 Health Services
Pabco Gypsum
Painters Trust
PBA
PEN Medicare Claims
Percs/Boyd Gaming
PHCS
philadelphia American Life Ins Comp
Pinnacle
Pipeline Industry Fund
Plumber and Pipefitters
Prime Silver State
Principal Financial
Priority Health
Prominence Health First
Providence Health
Regence
Reno Air
Security Life
Security Lilfe
Senior Dimensions
Sentinel
Sierra Health Medical
SIerrea Nevada Spectrum
Silver State Medical
South Point Benefits
Southwest Carpenters Health and Welfare
Spectera
State Farm Medicare Supplement
Station Casinos
Sterling Options
Summerlin Life & Health
Superior Vision
Teachers Health Trust
Teamsters Montana
Teamsters Security Fund
The Loomis Company
Tricare
True BLue
Twin City Optical
U.S. Safety
UHC Military services
UMR
United American Insurance
United Brotherhood of Carpenters
United Health Care
Universal Health Care
Universal Health Network
UPRR Health Services
Vision Benefits of America
Vision Care Advantage
Vision One(Discount Only)
Vision Service Plan (VSP)
Wellish
Wellish Co-Manage
Wells Fargo Third Party Admin.
Wisconsin Electrical Health & Welfare
WMI/TPA
Workers Comp-Liberty Mutual Insurance Company
Insurance Plan:
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:
Vision Insurance 3
Insurance Information
Insurance Name:
None
New Insurance
A2
ABMS
Advantica
Adventist Risk Management
ae
Aetna
Aetna
Alaska ELectrical Health & Welfare Fund
Altius
Ameriben
Ameritas
Anthem Vision
Armada Collections
Assurant Health
Avesis
Bankers Life & Casualty
BC/BS
BC/BS Federal Employees
Beech Street Corp.
Benefit Administrators
Benefit Planners
Benicorp
Brimhall
Capitol Administrators
Caremore
CDS Group Health
Cement & Concrete Workers
Champva
Chemical Lime Co.-Apex Plant
Chesterfield Resources Inc
Cigna
Cigna International
Clark County Self Funded
Clearwater Paper Corporation
Clovis
Coast Benefits
Coresource
Coventry
Crystal PM
Culinary
Custom Building Products
Cypress Benefit
dall
Davis
Definity
Electrical Workers
Eye Associates of Nevada
Eye care Associates
Eyeconic
Eyemed
First Health
Fiserv Health
Fiserv Health (Benefit Planners)
GE Financial
Geha
General Atomics
Gilsbar
Golden Rule
Great West
Green Flag Collections
Group Dental Insurance Plan
Group Resources
Guardian
Health Market Insurance Company
Health Partners
Health Plan of Nevada
Health Scope
Health Smart
HMA
HMA INC
Horseshoe (Binions)
Humana
IMX
Insurance discount plan
Jacobson MSO, Inc.
JAS INC.
John Alden
Lions Club
Loomis
Lumenos
Madison National
Mail Handlers
Major League Baseball
Medben
Medical Eye Services
Medical Mutual
Medicare
Mediversal
Meritain Health
Misc. 1
Misc. 2
Moda Health
Mutual of Omaha
National Automatic Sprinkler Industry
Nevada Care
New Eyes
New West Medicare
No Insurance
Operating Engineers
Opticare Of Utah
Other
P5 Health Services
Pabco Gypsum
Painters Trust
PBA
PEN Medicare Claims
Percs/Boyd Gaming
PHCS
philadelphia American Life Ins Comp
Pinnacle
Pipeline Industry Fund
Plumber and Pipefitters
Prime Silver State
Principal Financial
Priority Health
Prominence Health First
Providence Health
Regence
Reno Air
Security Life
Security Lilfe
Senior Dimensions
Sentinel
Sierra Health Medical
SIerrea Nevada Spectrum
Silver State Medical
South Point Benefits
Southwest Carpenters Health and Welfare
Spectera
State Farm Medicare Supplement
Station Casinos
Sterling Options
Summerlin Life & Health
Superior Vision
Teachers Health Trust
Teamsters Montana
Teamsters Security Fund
The Loomis Company
Tricare
True BLue
Twin City Optical
U.S. Safety
UHC Military services
UMR
United American Insurance
United Brotherhood of Carpenters
United Health Care
Universal Health Care
Universal Health Network
UPRR Health Services
Vision Benefits of America
Vision Care Advantage
Vision One(Discount Only)
Vision Service Plan (VSP)
Wellish
Wellish Co-Manage
Wells Fargo Third Party Admin.
Wisconsin Electrical Health & Welfare
WMI/TPA
Workers Comp-Liberty Mutual Insurance Company
Insurance Plan:
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 Insurance 1
Insurance Information
Insurance Name:
None
New Insurance
A2
ABMS
Advantica
Adventist Risk Management
ae
Aetna
Aetna
Alaska ELectrical Health & Welfare Fund
Altius
Ameriben
Ameritas
Anthem Vision
Armada Collections
Assurant Health
Avesis
Bankers Life & Casualty
BC/BS
BC/BS Federal Employees
Beech Street Corp.
Benefit Administrators
Benefit Planners
Benicorp
Brimhall
Capitol Administrators
Caremore
CDS Group Health
Cement & Concrete Workers
Champva
Chemical Lime Co.-Apex Plant
Chesterfield Resources Inc
Cigna
Cigna International
Clark County Self Funded
Clearwater Paper Corporation
Clovis
Coast Benefits
Coresource
Coventry
Crystal PM
Culinary
Custom Building Products
Cypress Benefit
dall
Davis
Definity
Electrical Workers
Eye Associates of Nevada
Eye care Associates
Eyeconic
Eyemed
First Health
Fiserv Health
Fiserv Health (Benefit Planners)
GE Financial
Geha
General Atomics
Gilsbar
Golden Rule
Great West
Green Flag Collections
Group Dental Insurance Plan
Group Resources
Guardian
Health Market Insurance Company
Health Partners
Health Plan of Nevada
Health Scope
Health Smart
HMA
HMA INC
Horseshoe (Binions)
Humana
IMX
Insurance discount plan
Jacobson MSO, Inc.
JAS INC.
John Alden
Lions Club
Loomis
Lumenos
Madison National
Mail Handlers
Major League Baseball
Medben
Medical Eye Services
Medical Mutual
Medicare
Mediversal
Meritain Health
Misc. 1
Misc. 2
Moda Health
Mutual of Omaha
National Automatic Sprinkler Industry
Nevada Care
New Eyes
New West Medicare
No Insurance
Operating Engineers
Opticare Of Utah
Other
P5 Health Services
Pabco Gypsum
Painters Trust
PBA
PEN Medicare Claims
Percs/Boyd Gaming
PHCS
philadelphia American Life Ins Comp
Pinnacle
Pipeline Industry Fund
Plumber and Pipefitters
Prime Silver State
Principal Financial
Priority Health
Prominence Health First
Providence Health
Regence
Reno Air
Security Life
Security Lilfe
Senior Dimensions
Sentinel
Sierra Health Medical
SIerrea Nevada Spectrum
Silver State Medical
South Point Benefits
Southwest Carpenters Health and Welfare
Spectera
State Farm Medicare Supplement
Station Casinos
Sterling Options
Summerlin Life & Health
Superior Vision
Teachers Health Trust
Teamsters Montana
Teamsters Security Fund
The Loomis Company
Tricare
True BLue
Twin City Optical
U.S. Safety
UHC Military services
UMR
United American Insurance
United Brotherhood of Carpenters
United Health Care
Universal Health Care
Universal Health Network
UPRR Health Services
Vision Benefits of America
Vision Care Advantage
Vision One(Discount Only)
Vision Service Plan (VSP)
Wellish
Wellish Co-Manage
Wells Fargo Third Party Admin.
Wisconsin Electrical Health & Welfare
WMI/TPA
Workers Comp-Liberty Mutual Insurance Company
Insurance Plan:
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 Insurance 2
Insurance Information
Insurance Name:
None
New Insurance
A2
ABMS
Advantica
Adventist Risk Management
ae
Aetna
Aetna
Alaska ELectrical Health & Welfare Fund
Altius
Ameriben
Ameritas
Anthem Vision
Armada Collections
Assurant Health
Avesis
Bankers Life & Casualty
BC/BS
BC/BS Federal Employees
Beech Street Corp.
Benefit Administrators
Benefit Planners
Benicorp
Brimhall
Capitol Administrators
Caremore
CDS Group Health
Cement & Concrete Workers
Champva
Chemical Lime Co.-Apex Plant
Chesterfield Resources Inc
Cigna
Cigna International
Clark County Self Funded
Clearwater Paper Corporation
Clovis
Coast Benefits
Coresource
Coventry
Crystal PM
Culinary
Custom Building Products
Cypress Benefit
dall
Davis
Definity
Electrical Workers
Eye Associates of Nevada
Eye care Associates
Eyeconic
Eyemed
First Health
Fiserv Health
Fiserv Health (Benefit Planners)
GE Financial
Geha
General Atomics
Gilsbar
Golden Rule
Great West
Green Flag Collections
Group Dental Insurance Plan
Group Resources
Guardian
Health Market Insurance Company
Health Partners
Health Plan of Nevada
Health Scope
Health Smart
HMA
HMA INC
Horseshoe (Binions)
Humana
IMX
Insurance discount plan
Jacobson MSO, Inc.
JAS INC.
John Alden
Lions Club
Loomis
Lumenos
Madison National
Mail Handlers
Major League Baseball
Medben
Medical Eye Services
Medical Mutual
Medicare
Mediversal
Meritain Health
Misc. 1
Misc. 2
Moda Health
Mutual of Omaha
National Automatic Sprinkler Industry
Nevada Care
New Eyes
New West Medicare
No Insurance
Operating Engineers
Opticare Of Utah
Other
P5 Health Services
Pabco Gypsum
Painters Trust
PBA
PEN Medicare Claims
Percs/Boyd Gaming
PHCS
philadelphia American Life Ins Comp
Pinnacle
Pipeline Industry Fund
Plumber and Pipefitters
Prime Silver State
Principal Financial
Priority Health
Prominence Health First
Providence Health
Regence
Reno Air
Security Life
Security Lilfe
Senior Dimensions
Sentinel
Sierra Health Medical
SIerrea Nevada Spectrum
Silver State Medical
South Point Benefits
Southwest Carpenters Health and Welfare
Spectera
State Farm Medicare Supplement
Station Casinos
Sterling Options
Summerlin Life & Health
Superior Vision
Teachers Health Trust
Teamsters Montana
Teamsters Security Fund
The Loomis Company
Tricare
True BLue
Twin City Optical
U.S. Safety
UHC Military services
UMR
United American Insurance
United Brotherhood of Carpenters
United Health Care
Universal Health Care
Universal Health Network
UPRR Health Services
Vision Benefits of America
Vision Care Advantage
Vision One(Discount Only)
Vision Service Plan (VSP)
Wellish
Wellish Co-Manage
Wells Fargo Third Party Admin.
Wisconsin Electrical Health & Welfare
WMI/TPA
Workers Comp-Liberty Mutual Insurance Company
Insurance Plan:
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:
Privacy Policy
Privacy Policy
Privacy Policy NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before the changes. In the event we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to doctors, nurses, technicians, medical students, or other people who are taking care of you for :(a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d) recall information. Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities, and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement. Health Care Operations: We may use and disclose your health information in connection with our healthcare operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certification, licenses and credentials we need to serve you. Marketing Health Care Products or Services: We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health care information. To Family and Friends: We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or payment for your healthcare, if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Required By Law: We may use or disclose your health information when we are required to do so by law, including judicial and administrative proceedings. 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 possible victim of other crimes. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. Appointment Reminders & Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. PATIENT RIGHTS Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you request copies we will charge you $ 0.50 for each page, and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and other specified exceptions. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. Electronic Notice: If you receive this notice on our Web site or by e-mail and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the Privacy Officer at our office. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint. Contact Person: Lawrence Wang, O.D. - Privacy Officer Telephone: 702-220-3937 Fax: 702-655-3182 Address: 7090 N. Durango Blvd. #110, Las Vegas, NV 89149
I have read and understood the Centennial Family Eyecare Privacy Policy.
>
Enhanced Testing
Advanced Testing
I would like an advanced digital retinal photogrpaph ($39) that helps the doctor detect early eye disease? (yes or no)
I would like to be screened by our skin caratenoid bioscanner to measure macular degeneration risk? ($30)(yes or no)
I would like a high definition OCT ultrasound of your optic nerves to measure glaucoma risk? ($30)
Yes or No
Medical History
Welcome to Centennial Family Eyecare: Dr. Lawrence Wang & Associates
Today's Date
Where was your last eye exam?
When was your last eye exam?
1 year
2 years
3 years
>4 years
>10 years
>15 years
>20 years
Other
What is your Occupation?
engineer
food server
nurse
pilot
Retired
Stay at Home Mother
Student
teacher
Other
Do you have any hobbies?
Crafts
Fishing
Golf
Music
Reading
Sewing
Shooting
Sports
Other
What is your preferred Nickname?
Patient since:
What is your Date of Birth:
Is there any eye disease in the family?:
Ethnicity:
White
Hispanic or Latino
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
(Declined)
Other
Prefered Language
English
Spanish
(Declined)
Other
Primary Care Physician & Other physician Names
What is the purpose of your visit today?
GL Exam
CL Exam
Eye Health Check
Diabeteic Exam
DMV Test
Eye Injury
Failed School Screener
First Eye Exam
First Time CL Wear
Hypertension Exam
Work Requirement
----------FOLLOW UP----------
CL f/u from:
Red eye f/u from:
Cataract Post Op
CL f/u, first time CL wear on:
CL fit
DFE
Dry eye f/u
Fundus Photo
GL Rx re-check from:
IOP ck
Medical f/u
VF repeat
Follow up
Do you have any Secondary Complaints?
None
GL Update
CL Update
Interested in CLs
Eye Health Check
Diabeteic Exam
DMV Test
Eye Injury
Failed School Screener
First Eye Exam
First Time CL Wear
Hypertension Exam
Work Requirement
----------FOLLOW UP----------
CL f/u from:
Red eye f/u from:
Medical f/u
Dry eye f/u
IOP ck
Cataract Post Op
CL fit
DFE
Fundus Photo
GL Rx re-check from:
VF repeat
Follow up
----------CONCERNS----------
Concern of Amblyopia
Concern of Cataracts
Concern of Diabetes
Concern of Glaucoma
Concern of Hypertension
Concern of Keratoconus
Concern of Macular Degeneration
Concern of Nevus
Concern of Retinal Health
----------SYMPTOMS----------
No VA Concerns
Blurred Vision
Distance Blur
Near Blur
Intermediate Blur
Sudden Loss of Vision
CL Discomfort
Glare
Ache
Burning Sensation
Crustie
Curtain Effect
Distorted Vision
Double VIsion
Dryness
Eye Turn
Flashes of Light
Floaters
Foreign Body Sensation
Haze/Mist
Haloes
Headaches
Irritation
Itchiness
Keratoconus
Lid Mass
Lids stuck together in AM
Mattering
Pain
Redness
Stinging
Tearing
Tired/Fatigue
Watery
Other
What is your contact lens history?
Have you had any Eye Surgeries?
None
Blepharoplasty
IOL OD
IOL OS
IOL OU
Lasik Dist. OU
Lasik Mono
Lasik OD
Lasik OS
RD Laser
RD Repair
Scleral Buckle OD
Scleral Buckle OS
Scleral Buckle OU
Vitrectomy
Other
Other Surgeries:
Do you have any drug allergies?
What Medications are you taking?
Allergy
Cholesterol
Diabetes
Heart
HTN
Thyroid
Other
What Other medications are you taking?
Who Referred you today?
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