Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
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:
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
Misc/Guardian

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
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 Information

Insurance Name:	None Advantica Cigna Vision Davis NVA Solstice 10,20,50 Superior Vision UHC/Spectera VSP
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:

Secondary Insurance

Insurance Information

Insurance Name:	None Advantica Cigna Vision Davis NVA Solstice 10,20,50 Superior Vision UHC/Spectera VSP
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:

Tertiary Insurance

Insurance Information

Insurance Name:	None Advantica Cigna Vision Davis NVA Solstice 10,20,50 Superior Vision UHC/Spectera VSP
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 History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

What is your main reason for visit?:

no complaint blurry vision broken glasses burning discharge double vision dryness failed DMV failed vision screening flashes floaters headaches injury to eye itching laser vision consultation light sensitivity loss of vision lost glasses pain redness referred by MD routine exam stinging strain tearing want new eyeglasses wants contact lenses Other

Do you wear glasses?:	Yes	No
If yes, do you wear them for:	Distance	Near	Both
Do you wear Contacts?:	Yes	No

Date of Last Eye Exam:
Date of Last Medical Exam:
Primary Care Physician:

Do you have any allergies to medication?:

Yes

No

If yes, please list:

Do you have seasonal allergies?:	Yes	No
Are you taking medications?:	Yes	No

List Medications:

List Eye Medications:

Do you have:

None

High Blood Pressure

Diabetes

High Cholesterol

Thyroid Disease

Rheumatoid Arthritis

Sexually Transmitted Disease

Heart Disease

HIV/AIDS

Cancer

Other

Have you ever had:

None

Strabismus (eye turn)

Cataracts

Eye injury

Amblyopia (lazy eye)

Glaucoma

Diabetic Retinopathy

Macular Degeneration

Dry Eyes

Retinal Disease

Cataract Surgery

Lasik/PRK

Retinal Detachment

Strabismus Surgery

Other

Does anyone in your family have:

Condition	Mother	Father	Grandmother	Grandfather	Siblings
Cancer
Diabetes
Cholesterol
Hypertension
Heart Disease
Thyroid
Blindness
Glaucoma
AMD
Amblyopia
Strabismus
Eye Cancer

Other

Are you pregnant?:	Yes	No
Do you see flashes of light in your eyes?:	Yes	No
Do you see floating objects in your eyes?:	Yes	No
Do you have frequent headaches?:	Yes	No
Do you smoke?:	Yes	No
Do you drink alcohol?:	Yes	No
Are you nursing?:	Yes	No
Do you have temporary blackouts of your vision?:	Yes	No
Former smoker?:	Yes	No

Occupation:

Number of hours spent on computer:

Dry Eye Questionnaire

1. Questions about EYE DISCOMFORT:

a. During a typical day in the past month, how often did your eyes feel discomfort?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?

0-Never have it 1-Not at all intense 2 3 4 5-Very intense

2. Question about EYE DRYNESS:

a. During a typical day in the past month, how often did your eyes feel dry?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day within two hours of going to bed?

0-Never have it 1-Not at all intense 2 3 4 5-Very intense

3. Question about WATERY EYES:

During a typical day, in the past month, how often did your eyes look or feel excessively watery?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

Submit Data, Policies, Consents

CONSENTS & INFORMATION

PATIENT CONTACT LENS INFORMED CONSENT AND CONTACT LENS REGIMEN FORM

Click here for full Contact Lens Consent

Click here for Spanish Contact Lens Consent and testing info

I UNDERSTAND THAT THE FDA (THE UNITED STATES FOOD AND DRUG ADMINISTRATION) REGULATES CONTACT LENSES (CONTACTS), GIVEN THAT THEY ARE CONSIDERED MEDICAL DEVICES.

WARNING:
KERATITIS, OR INFLAMMATION OF THE CORNEA, IS ONE OF THE MOST SEVERE COMPLICATIONS OF THE OCULAR SURFACE THAT CAN LEAD TO SCARRING THE CORNEA AND/OR SIGNIFICANT OR COMPLETE VISION LOSS. ONE CAUSE OF KERATITIS IS SECONDARY TO CONTACT LENS WEAR. CONTRIBUTING FACTORS ALSO INCLUDE, BUT NOT LIMITED TO; SMOKING, PREVIOUS EYE INJURIES, PREVIOUS EYE SURFACE CONDITIONS, TRAUMA, POOR HYGIENE OR LENS CARE, CONTACT LENS OVERWEAR, AND/OR CONTACT LENS PRODUCTS. HOWEVER, SLEEPING IN YOUR CONTACTS, POSES THE GREATEST RISK FOR COMPLICATIONS.

ADDITIONAL INFORMATION CAN BE FOUND ON THE FOOD AND DRUG ADMINISTRATION WEB SITE

I UNDERSTAND THAT THERE ARE BOTH BENEFITS AND RISKS TO WEARING CONTACT LENSES. THE BENEFITS INCLUDE IMPROVED VISION, COSMETIC APPEAL, AND/OR CONVENIENCE. I UNDERSTAND THAT PROPER USAGE AND CARE OF MY CONTACT LENSES, LENS CARE PRODUCTS, AND LENS CASES ARE CRITICAL TO SAFE WEAR OF CONTACT LENSES. I UNDERSTAND THAT SERIOUS DAMAGE TO THE EYE, SCARRING OF THE CORNEA, AND VISION LOSS CAN RESULT FROM PROBLEMS ASSOCIATED WITH WEARING CONTACT LENSES, IMPROPER LENS CARE HABITS, AND UTILIZING LENS CARE PRODUCTS.

PROPER CARE FOR MY CONTACT LENSES INCLUDE, BUT IS NOT LIMITED TO, PROPER CONTACT LENS AND CONTACT LENS CASE CARE, ADHERING TO MY WEARING SCHEDULE, REPLACEMENT SCHEDULE, RECOMMENDED SOLUTIONS AND PRODUCTS, AND PRESENTING MY FOLLOW-UP APPOINTMENTS AND YEARLY EYE EXAMINATIONS. I UNDERSTAND THAT FAILURE TO COMPLY WITH THE PREVIOUS STATEMENTS COULD RESULT IN DAMAGING MY EYES AND/OR IN TERMINATION OF CONTACT LENS WEAR BY THIS OFFICE.

I UNDERSTAND THAT IT IS POSSIBLE FOR PROBLEMS, INCLUDING CORNEAL ULCERS, TO RAPIDLY DEVELOP AND LEAD TO VISION LOSS. I UNDERSTAND THAT IF I EXPERIENCE ANY EYE DISCOMFORT, SENSITIVITY TO LIGHT, BURNING, ITCHING, EXCESSIVE TEARING, REDNESS, DECREASED VISION, PAIN, DRYNESS, UNCOMFORTABLE LENS SENSATION, OR ANY UNUSUAL EYE SECRETIONS AND SYMPTOMS TO IMMEDIATELY REMOVE MY CONTACT LENSES AND PROMPTLY CONTACT THIS OFFICE AT 434.973.7996

IMPORTANT:REGARDLESS OF WHERE YOU PURCHASE CONTACTS; YOUR WEARING SCHEDULE, SOLUTION, REPLACEMENT SCHEDULE, CARE REGIMEN, FOLLOW-UP & EXAMS REMAIN THE SAME.

I FULLY UNDERSTAND THE RISKS AND BENEFITS OF WEARING CONTACT LENSES. I AGREE TO RETURN FOR MY FOLLOW-UP VISIT WHOSE MAIN PURPOSE IS TO ENSURE THE SAFETY OF MY EYES. BY SIGNING
THIS CONSENT I AGREE TO ADHERE TO THE CONTACT LENS INSTRUCTIONS AS STATED ABOVE.

Patient Signature: Date:

HEALTH CARE SERVICES:

- I authorize consent for medical treatment at CG EyeCare of Florida, INC. (CGEFL)
- (HIPPA) Health Insurance Portability and Privacy Act of 1996 requires that CGEFL (the practice) provide you a copy of, or access
to, our notice of privacy practices. I acknowledge that I have been presented the opportunity to read the notice of privacy practices and
that I do not wish to have any exceptions.

MINORS:

I give permission for my child to have any diagnostic drops or contact lens service for an eye exam or contact lens fitting

FINANCIAL/INSURANCE:

- Valid insurance must be presented at the time of visit to be applied to the current visit only. It is your responsibility to know your
insurance information in order for (CGEFL) to file a claim on your behalf. We (CGEFL) try our best to find insurance coverage
on your behalf, however, if no insurance is presented or found at the time of visit (CGEFL) is not responsible for filing back
dated claims at a later time and the patient is responsible for all fees associated with their visit.

- Payment is required at the time of service. If services are billed to an insurance carrier, I authorize that payment of any insurance
benefits either to me or on my behalf be made to (CGEFL) for any services furnished to me or my dependents. I understand that if
my insurance company does not provide payment to (CGEFL), I will be billed for the non-covered services and that I am
responsible for payment when I receive the bill. If payment is not made within 30 days from the date the bill was mailed from
(CGEFL),I understand that a 5% charge will be added to my bill after each 30 days.

-Responsible for payment when I receive the bill. If payment is not made within 30 days from the date the bill was mailed from
(CLE), I understand that a 5% charge will be added to my bill after each 30 days.

- To collect any outstanding amount owed to CGEFL; you may be contacted by any telephone number,
including wireless telephone numbers, that are associated with your account and can result in charges to you. Methods of contact
may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable
by a collection service company.


Specialty Testing

DILATION:

- (enlargement) of the pupils is Florida's standard of care for all new patients and is often done on subsequent visits. It
increases the field of vision inside of the eye, thereby, allowing a more thorough examination of the ocular health.

- It is included and recommended as part of today's comprehensive eye examination.

- Dilating drops are used to dilate or enlarge the pupils of the eye. They frequently blur vision for a length of time which varies from
person to person and cause sensitivity to lights, therefore, it is not possible to predict how much your vision will be affected. Caution
should be exercised while walking down steps, operating machinery or performing other tasks that may present a risk of injury.

- Adverse reactions such as acute angle-closure glaucoma may be triggered from the dilating drops. This reaction is extremely rare and
is treatable with immediate medical attention.

I, , understand the side effects and benefits of dilation and I AGREE to having my eyes
dilated today. I hereby authorize CGEFL associates to administer dilating eye drops.

I, , understand the side effects and benefits of dilation and i DO NOT AGREE to having my
eyes dilated today.

Retinal Photo:

Yes, I elect to have an Optomap taken today for $29.00

No, I decline the Optomap option today.


I acknowledge that I have read this form, I understand its content, and do not have any questions. I am the patient or the person duly authorized
either by the patient or otherwise, sign this agreement, consent to, and accept its terms. I am responsible for the payment and/or co-payment that
is due at the time of service, and I have been given the option to for a copy of the CG Eyecare of Florida HIPPA Policy.


                                    
Patient (or person authorized to sign for patient)                                                          Date: