Patient information

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Primary Vision Insurance


Primary Medical Insurance

Personal History

Reason's For Visit (Please Select All That Apply)

Ocular History: Review Of Systems

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Have YOU or anyone in your IMMEDIATE FAMILY ever been diagnosed with an Ocular Condition?
Myself Family Condition
Macular Degeneration
Dry Eyes
Lazy Eye

Medical History

Have YOU or anyone in your IMMEDIATE FAMILY ever been diagnosed with a Medical Condition?
Myself Family Condition
High Blood Pressure
Multiple Sclerosis
Thyroid Disease

Social History

Please remember to bring the following items with you to your exam:

  • Vision and Medical Insurance Cards
  • Copy of previous prescriptions (if available)
  • Current Glasses - distance, reading, sunglasses, and computer glasses
  • Current Contact Lens Prescription (a photo of the numbers on the boxes will work)
  • List of current medications
  • Any drops you are currently using

  • Patient Signatures

    Retinal Photo and 3D OCT Scan:

    We believe checking your Eye Health is just as important as checking your Vision. This non-invasive test plays a major role in early detection and monitoring of many eye diseases such as diabetes, glaucoma, macular degeneration and retinal detachments. These conditions can lead to serious problems, including loss of vision or blindness. Many ocular conditions often develop without warning and can progress with no symptoms, as there are no pain receptors in the back of the eye. These retinal images become a permanent part of your medical record and will allow our doctor to monitor and track the health of your eyes on an annual basis. It is our office policy for this procedure to be performed on All Patients. The retinal screening fee is $39. The fee is included in our private pay pricing, but insurance plans typically do not cover this screening. (Pupil dilation may still be required.)

    HIPAA Compliance Patient Consent Form

    Notice of Privacy Practices: I acknowledge, by my signature below that I have been given the opportunity to review the Notice of Privacy Practices for Russell Liles, OD, PLLC and I understand that I may request a copy of this notice should I so choose.

    Financial Agreement: I understand my insurance company may make payment directly to Russell Liles, OD, PLLC for services and/or materials rendered. I understand that Russell Liles, OD, PLLC may release information about me or my dependents necessary to process any and all claims for reimbursement on my behalf.

    Authorization to Treat: I authorize Russell Liles, OD, PLLC, its agents, and employees (collectively referred to as "healthcare providers") to furnish optometric care and services, including but not limited to, diagnostic tests, examinations, and other medical and/or surgical procedures which is deemed necessary in the course of my care.

    I understand and agree to decline pupil dilation today. If any condition arises in the future which may have been detected by pupil dilation, I will not hold Dr. Liles or his staff responsible.

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