Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Parent/Guardian

Eye History

Reason for Visit:
Secondary Concerns:
Eye Symptoms:
Eye Meds/Drops:
Eye Surgeries:
Last Eye Exam: Previous Eye Doctor:

Primary Vision Correction:
Want new glasses?: Prescription sunglasses?:

Type of contact lenses worn in past:
Cleaner: Wear Time: Disposal: Is this your first time using contacts?:
Previous Contact Lens Brand:
Previous Prescription: (if known)
      Sphere Cylinder   Axis
BC OD: X
BC OS: X

Medical History

Primary Care Physician:
Recent Tetanus Shot?: Pregnant Or Nursing:

Are you taking any medications/supplements, or have any allergies? If no, please type 'None'.

Medications:
Over The Counter Medications:
Drug Allergies:
Vitamins:

Personal/Family History



Please use the blank space next to each condition to include additional details or alternate family members.

Eye History

(None For All)
 Self  Mom  Dad  Sibling
Eye Turn         
Lazy Eye         
Glaucoma         
Cataracts         
Macular Degeneration         
Retinal Detachment         
Blindness         
Keratoconus         

Medical History

(None For All)
 Self  Mom  Dad  Sibling
Cancer         
Diabetes         
High Blood Pressure         
Stroke         
Thyroid Disease         
High Cholesterol         
Heart Condition         
Other Disease

Social History

STD:

Smoking Status: Type: How Long
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long:

Race: Ethnicity: Preferred Language:

Review of Systems

General: Ear/Nose/Throat:
Cardiovascular: Respiratory:
Genitourinary: Musculoskeletal:
Gastrointestinal: Skin:
Neurological: Psychiatric:
Endocrine: Blood/Lymph:
Allergy/Immune: Other:

Submit Form / Patient Signatures



NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so, or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our front desk.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

A full copy of our Notice of Privacy Practices is available on our website, www.qaeye.com under Patients > Notice of Privacy Practices, or is available at the following link: https://qaeye.com/assets/forms/privacy_practices.pdf

By my signature below, I acknowledge receipt of the notice of Privacy Practices & Office Policies. This will be retained in your medical record.

Signature: Date:

OFFICE POLICIES:

  • The evaluation of contact lenses is not included in the comprehensive exam. An additional charge will be issued for this service. Fees for services (fitting, evaluation, and training) for soft contact lenses range from $30-$120. Evaluation for specialty and therapeutic contact lenses vary depending on complexity.
  • All contact lens orders must be paid in full at time of order. All eyewear orders require a minimum deposit of 50% before the order can be processed. Eyeglass lenses are custom made and cannot be refunded. However, remakes may be necessary to finalize your prescription. One remake will be done free of charge if done within 60 days of dispensing.
  • Queen Anne Eye Clinic will file insurance claims and await payment from your insurance company, but we cannot guarantee coverage by your insurance company, and you are ultimately responsible for any balances incurred. We will send you a statement if a balance remains, which is due within 30 days of notification. If payment is not received after 90 days, your account will accrue a 1% finance charge every month until payment is made. A $25 fee will be assessed for all returned checks.


  • Signature: Date:

    Optomap Consent

    We are proud to offer state-of-the-art digital retinal imaging technology, which allows our doctors to view the inside of the eye without requiring dilating drops. The Optomap Retinal Scan allows us to evaluate your retina for a number of problems, some of which may be present without any symptoms. This scan does not emit any radiation and is completely safe for patients of all ages. After the scan is performed, you have the opportunity to review the inside of your eyes with your doctor, and can even be provided with a copy of your image at your request. The Optomap also allows the doctor to see up to 200 degrees at once, whereas traditional methods only allow up to 45 degrees to be viewed at once (see below).



    Dilated Exam

    - Blurred Near Vision For 4-6 Hours
    - Light Sensitivity For 4-6 Hours
    - No Permanent Record Of Retina
    - Longer Office Visit (Drops Usually Take
    10-15 Minutes To Take Effect)
    Optomap Retinal Exam

    - NO Blurred Vision
    - NO Light Sensitivity
    - Digital Image Stored For Future Comparison
    - You May View Images
    - Takes Less than 2 Minutes To Capture The Image.




    Most major insurance companies do not cover the Optomap screening. There is an additional fee of $39, which is generally reimbursable through flexible spending (FSA). In rare instances, the doctor may still require dilation after the screening has been performed to further asses any abnormal findings.

    Optomap Signature

    I elect to have Optomap Retinal Scan performed as part of my eye health exam
    I elect not to have Optomap Retinal Scan performed as part of my eye health exam