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Patient Information


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
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 How Did You Hear About Us?


Billing Information

Is The Billing Address the Different?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Vision Insurance


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


Medical History

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

Reason For Visit
Reason for Visit:

Routine/Glasses Exam Dry Eye Evaluation
Contact Lens Exam Glaucoma Evaluation
LASIK Evaluation Specialty Contact Lens Fit
Retinal Evaluation/Imaging Other


Medical Conditions (Check All That Apply):
Disease Person Affected Comments/Who?
High Blood Pressure Self Family
High Cholesterol Self Family
Diabetes Self Family
      How Many Years? Last HBA1C? Date
      OMD Care? Yes No Last Date?
Heart Disease Self Family
AutoImmune Disease Self Family
Cancer Self Family
HIV Self Family
Kidney Disease Self Family
Lupus Self Family
Major Surgery Self Family
Thyroid Self Family

Other
Surgeries Date


Medications
Medications

Allergies To Medications (Check All That Apply):

Allergies To Medications Yes No
Penicillin Sulfa
Latex Rubbing Alcohol

Other Allergies


Review Of Systems (Check All That Apply):
Systems Affected Comments
Constitutional (Fever, weight change, fatigue)
Ear, nose, or throat (Hearing loss, sinus, sore throat)
Heart (chest pain, irregular hear beat)
Respiratory (wheeze, cough, shortness of breath)
Gastrointestinal (heartburn, diarrhea, )
Genitourinary (painful urination, blood in urine)
Musculoskeletal (Muscle ache, joint paint, swollen joints)
Skin (Rashes, excessive dryness, bumps)
Neurological (Numbness, weakness, blackouts)
Psychiartic (Depression, anxiety)
Endocrine (Thyroid, frequent urination, thirst)
Blood/lympth (Bruising, swollen glands)
Immune (Frequent infections, allergies) Other


Social History
Do you use smoke or use tobacco products?
Do you drink alcohol?
Do you use any illegal substances?


Ocular History


Ocular History
Last Eye Exam Do You Wear Glasses? Yes No Type of Glasses
Date:                    


Current Symptoms (Check All That Apply):
Blurred Distance Vision Lost/broke Glasses
Blurred Near Vision Out of Contacts
Blurred Computer Vision Eye strain
Dry Eyes Itchy Eyes
Eye Pain Eye Turn
Light Sensitive Glare
Redness Loss of Vision
Flashes of Light Floaters

OTHER


Previously Diagnosed Conditions (Check all that apply):
Disease Person Affected Specify?
Amblyopia (Lazy Eye) Self Family
Blindness Self Family
Cataract Self Family
Diabetes in the eye Self Family
Eye Injury Self Family
Eye Surgery Self Family
Glaucoma Self Family
Macular Degeneration Self Family
Strabismus (Eye Turn) Self Family
Retinal Disease Self Family
Other
Eye Surgery Or Trauma
Interested In LASIK?


Dry Eye Questionnaire (Check All That Apply):
Burning Teary/watery eyes Blurred Vision
Stinging Scratchiness Grittiness
Redness Irritation


Computer Use History (Check All That Apply):


How many hours of computer use per day?
Eye strain Eye fatigue Light sensitivity
Blurred vision Headaches Glare




Contact Lens History - First Time Contacts
What type of contacts do you wear?
What brand of contacts do you wear?
How often do you replace your lenses?
How many days per week do you wear your lenses?
Which solution do you use?
Do you sleep in your contacts?

COVID - 19

COVID - 19 Screening Questions

COVID - 19 Screening Questions


1) Have You Had A Positive Diagnosis Of COVID-19?
Yes No
2) Are You Currently Experiencing Any Of The Following Symptoms?
Fever / Chills / Sweats Myalgia (Body Aches)
Cough Loss Of Taste And / Or Smell
Shortness Of Breath Diarrhea
Sore Throat Nausea
Nasal Congestion / Runny Nose Vomiting
3) Have You Had Close Contact With An Individual Diagnosed With Or Is Under Investigation For COVID-19?
Yes No

Retinal Imaging


Retinal Imaging

Retinal Evaluation


The Optomap Digital Retinal Imaging can detect many eye diseases such as glaucoma, macular degeneration, retinal detachments, diabetic retinopathy and other sight-threatening diseases. Digital retinal evaluations per your optometrist an in depth view of the inside of your eyes and can also assist in early detection for systemic diseases such as diabetes, hypertension, high cholesterol and other abnormalities. The images will also be used to document and observe any changes in the eyes at future appointments.

Our doctors highly recommend that all patients have this procedure performed routinely, every year.



Medical and vision insurances do not pay for routine retinal photos. The procedure is offered at $29.

YES, I WOULD like to have my retinal health evaluated with the Optomap Digital Retinal Imaging today for a $29 fee.

NO, I DO NOT want to have my retinal health evaluated with the Optomap Digital Retinal Imaging today. I would like to discuss the option of dilation and understand the risks of potential missed or delayed diagnoses associated with declining a retinal evaluation.

Policies / Submit


Policies / Submit

Assignment of Benefits


I hereby authorize and direct my insurance carrier to issue payment directly to Eye People Optometry for healthcare services provided to me. I also authorize Eye People Optometry to release any information required for payment to be made. My signature below verfies that I understand this agreement.

Financial Responsibility


Payment for all materials and professional services rendered is due at the time of service. I understand that I am financially responsible for copay, coinsurance and/or deductible at the time of service and for any materials or services rendered that are determined to be "non-covered services" by my insurance plan.

I understand that my if my insurance does not pay, or partially pays, the full amount for services rendered and materials dispensed, that I am responsible for any amount not payable by my insurance.

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for services and to conduct health care operations involving our office.

The Privacy Policy describes these uses and disclosures in detail. You are entitled to a copy of our Privacy Policy and is available at your request and is posted in our clinic. I acknowledge that a copy of the Privacy Policy and is readily available to me from Eye People Optometry.

Contact Lens & Specialty Service Fees


Contact lens fitting services, specialty evaluations (i.e. dry eye evaluations, myopia control) and specialty diagnostic testing/imaging are not an included part of a comprehensive eye exam and additional fees apply. Fees are dependent on the type of evaluation, contacts, diagnostic testing/imaging and complexity of the case. My signature below verifies I understand the contact lens and specialty service fees.

Return Policy


Due to the specialized and custom nature of eyewear, there are no returns or exchanges for any purchased eyewear and eyecare products (including but not limited to lenses, frames, sunglasses, contacts, sprays, cloths, etc). If there is a change in prescription after receiving the new lenses, the lenses can be redone one-time at no charge within 90 days. All of our frames and lens coatings have a one-year warranty for any manufacturer defects from the date of purchase, which does not include accidental damage or normal wear and tear. Any eyewear not picked-up within 90 days from the order date will be disassembled and all deposits will be forfeited. My signature below verifies I understand the return policy.

Frame Adjustments & Patient's Own Frame


We offer complimentary frame adjustments however all adjustments are done at your own risk as we are not responsible should the frame break during adjustment, removal or reinsertion of lenses. If you would like to use your own frame and put in new lenses, we will gladly reuse your own frame if the frame is suitable to have new lenses. The optician will inspect the frame and has the right to decline reuse of the frame. This is done at your own risk as our office or labs we use are not responsible should the frame break, substain damage during the lens fabrication process or loss by mail carrier. For irreplaceable frame designs that are no longer manufactured, we strongly recommend purchasing new frames as warranties are included. My signature below verifies I understand the policy.

Please check, sign, and date that you have read and agree to our policies and click the SUBMIT button to complete your online forms.

Check:
Patient / Guardian Signature:
Date:




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