Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian



Medical

Primary Medical Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Secondary Medical Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision

Primary Vision Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Secondary Vision Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
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!

Reason for Visit: Secondary Reasons:

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? If yes, please describe:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Review of Systems

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

Social History

Hobbies: STD's:

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

Race: Ethnicity: Preferred Language:


Speed Questionnaire

For the Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire, please answer the following questions by checking the box that best represents your answer. Select only one answer per question.

1. Report the type of SYMPTOMS you experience and when they occur:

  At This Visit Within Past
72 Hours		 Within Past
3 Months
Symptoms Yes     No Yes     No Yes     No
Dryness, Grittines Or Scratchiness            
Soreness Or Irritation            
Burning Or Watering            
Eye Fatigue            


2. Report the FREQUENCY of your symptoms using the rating list below:

Symptoms Frequency
Dryness, Grittines Or Scratchiness
Soreness Or Irritation
Burning Or Watering
Eye Fatigue

0 = Never    1 = Sometimes    2 = Often    3 = Constant

3. Report the SEVERITY of your symptoms using the rating list below:

Symptoms Frequency
Dryness, Grittines Or Scratchiness
Soreness Or Irritation
Burning Or Watering
Eye Fatigue

0 = No Problems
1 = Tolerable - Not Perfect, But Not Uncomfortable
2 = Uncomfortable - Irritating, but Does Not Interferes With My Day
3 = Bothersome - Irritating And Interferes With My Day
4 = Intolerable - Unable To Perform My Daily Tasks

4. Do you use eye drops for lubrication? Yes No   If yes, How Often?



Lifestyle Form

How Often Do You Experience Any Of These Symptoms?

You Get Headaches Of Any Severity Each Week (even just a dull ache counts).
Your Headaches Tend To Get Worse Later In the Day.

  1 2 3 4 5
  Never Rarely Sometimes Very Often Always
Headaches
  Additional Notes


You Experience Stiffness / Tension in your Neck / Shoulders When You Work At A Computer Or Read (this might even be from your posture).

  1 2 3 4 5
  Never Rarely Sometimes Very Often Always
Stiffness / Pain In Neck / Shoulders
  Additional Notes


Your Eyes Get Tired, Burn, Or Get Red Easily When You Work At A Computer For Long Hours.

  1 2 3 4 5
  Never Rarely Sometimes Very Often Always
Discomfort With Computer Use
  Additional Notes
  Number Of Hours Per Day Using A Digital Device


Your Eyes Feel Increasingly Fatigued / Tired As The Day Goes On.

  1 2 3 4 5
  Never Rarely Sometimes Very Often Always
Tired Eyes
  Additional Notes


Your Eyes Progressively Feel More Dry / Sandy / Gritty While Working At The Computer Or Reading.

  1 2 3 4 5
  Never Rarely Sometimes Very Often Always
Dry Eye Sensation
  Additional Notes


Bright / Strong Lights (vehicle headlights, florescent lights etc.) Bother You.

  1 2 3 4 5
  Never Rarely Sometimes Very Often Always
Light Sensitivity
  Additional Notes


You Experience Dizziness, Motion Sickness, Or Vertigo.

  1 2 3 4 5
  Never Rarely Sometimes Very Often Always
Dizziness
  Additional Notes


Additional Notes Any Additional Notes You'd Like To Add:


Submit Data

Please scroll to bottom of this tab and press the Submit Data button to submit your information.

**Click here to view our Notice of Privacy Practices**

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

The law requires that Clear lake Eye Center make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that: (check one)







I have read and understand this form. I am signing it voluntarily. I am aware that I may request a copy of the Notice of Privacy Practices.

Signature: Date:

If you are signing as a personal representative of the patient, please indicate your relationship.

Representative Signature: Relationship to Patient:

Screening Test Waiver

The Optomap retinal photo, Visual Field Testing, and OCT scan will be performed annually for every patient UNLESS a waiver is signed.

The fee is only $61.00 (it is not usually covered by insurance).

Our doctors want ALL patients to have the following screening tests to be performed annually as part of your yearly exam to better assess the health of your eyes:
  • The Optomap retinal photo is used to get an ultra-wide field photo of the retina (the back of the eye) in order to thoroughly screen the health of your eyes without dilation. The photo is taken quickly, painlessly, and can be used to track the health of your eyes from year to year. In many cases, the Optomap photo is a good option instead of dilation. However, Optomap does not guarantee that you won't be dilated. If a medical condition is found, you may still be dilated for further evaluation.
  • A visual field screening test is a quick and painless interactive test that can detect dysfunction in central and peripheral vision.
  • The Optical Coherence Tomography (OCT) screening is a non-invasive imaging test that uses light waves to take cross-section pictures, like an MRI of your retina. Together these measurements help with early detection for retinal diseases and condition, including macular degeneration, glaucoma, diabetic eye disease, stroke, brain tumors, among others.
Retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments and diabetic retinopathy can now be seen without dilation for most patients.

Waiver and Release of Liability for Internal Eye Health Exam

I have been informed that a thorough internal examination of the eye is integral to an eye examination. Without a thorough internal examination serious eye disease can be missed such as: diabetes, retinal holes/tears/detachment or malignant tumors.

I understand that all of these can lead to loss of vision, blindness or even death.

I would like the following optional screening tests to be performed today: PLEASE CHECK ONE







Explanation of Contact Lens Exam and Evaluation Fees

The cost for an annual comprehensive eye examination is $165-$195. This includes a glaucoma test, dilation, and will test the overall health of your eyes. This DOES NOT include the evaluation for contact lenses.

A contact lens prescription needs to be updated every year in order to purchase more lenses for the next 12 months.

If you are new to contact lenses, we will set up a one on one training session with a contact lens technician. We will teach you the proper care and correct insertion and removal of the lenses. *The fees will be $180 for soft lenses and $250 for RGP (Rigid Gas Permeable) lenses. This fee will include all diagnostic soft lenses, up to an hour of training per visit for up to 3 months, and a finalized contact prescription.

For previous contact lens wearers:
The soft contact lens fit and corneal evaluation fees will range from $70-$125 depending on the type of lenses prescribed.

The RGP lenses (Rigid Gas Permeable) fitting fee will range from $125-$180. For all RGP lens wearers, the payment for your contact lenses will be collected on the day of your examination. We will not be able to order your contacts prior to receiving payment for those lenses.

The doctor or contact lens technician will explain the fitting fee charges as they apply.

Contact lens progress visits are included with your fitting fees for up to 3 months following your examination; thereafter contact lens related visits are the patients responsibility. The office visit will start at $75 with the possible addition of a $35 refraction if it is indicated.

Contact lens exam and fitting fees are non-refundable. (Please check one)





By signing this I agree to what I chose above for the optional testing and contact fittings.

Signature: Date:

Patient Consent Form

I allow release of medical information to the following:

First Name Last Name
First Name Last Name
First Name Last Name


I allow the following person(s) to pick up prescriptions, glasses, and/or contacts on my behalf, with the appropriate ID:

First Name Last Name
First Name Last Name
First Name Last Name


Cancellation Policy

  • Cancellations must be made at least four hours ahead of your appointment time.
  • Notification should be made via the office voice mail, or texting the office phone number if the cancellation occurs before the start of office hours.
  • No claims will be made to insurance companies if the patient is not seen in the office.
  • Patients who skip their appointment will be charged $25.00. Patients who fail to provide four hours of advance notice will also be charged $25.00. This is a universal charge that is applied equally to all patients, regardless of their insurance status.

Printed Name Date
Signature