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 New Insurance AARP Discount Advantica Aetna Aetna D% Anthem Benefit Concepts Carefirst Administrators Cigna Cigna (Medical) Coventry Health Care Davis Discount Davis Vision Eyemed GEHA Golden Rule Ins Co Humana Metlife Military Multiplan Optima Optima Health (Medical) Self Pay Spectera Spectera Discount Staunton Discount Superior Vision TLC Comanagement Tricare For Life UMR Unicare United Healthcare Unverified VSP VSP Discount
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 New Insurance AARP Discount Advantica Aetna Aetna D% Anthem Benefit Concepts Carefirst Administrators Cigna Cigna (Medical) Coventry Health Care Davis Discount Davis Vision Eyemed GEHA Golden Rule Ins Co Humana Metlife Military Multiplan Optima Optima Health (Medical) Self Pay Spectera Spectera Discount Staunton Discount Superior Vision TLC Comanagement Tricare For Life UMR Unicare United Healthcare Unverified VSP VSP Discount
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 New Insurance AARP Discount Advantica Aetna Aetna D% Anthem Benefit Concepts Carefirst Administrators Cigna Cigna (Medical) Coventry Health Care Davis Discount Davis Vision Eyemed GEHA Golden Rule Ins Co Humana Metlife Military Multiplan Optima Optima Health (Medical) Self Pay Spectera Spectera Discount Staunton Discount Superior Vision TLC Comanagement Tricare For Life UMR Unicare United Healthcare Unverified VSP VSP Discount
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
Heart Disease
Hypertension
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:

Click here to view our Policy's (English)

Click here to view our Policy's (Spanish)

MINORS:

I give permission for my child to have any diagnostic drops or contact lens service which may be required for an eye
exam or contact lens fitting.

FINANCIAL/INSURANCE:

Dilation
Yes, I, , understand the side effects and benefits of dilation and hereby authorize administering the dilating eye drops

No, I, , understand that I am opting against what is recommended for my comprehensive ocular health by the optometrist.

Retinal Photograph:
Acquires a digital image of the back of the eye to allow the optometrist to look for diseases and track changes over time.

I will have an OPTOMAP (retinal photo) taken today for a co-pay of $34.00

I understand that I am opting against what is recommended for my ocular health by the optometrist


I acknowledge that I have read this form and understand its content. 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 for a copy of the CLE HIPPA Policy


                                    
Patient (or person authorized to sign for patient)

Specialty Testing

Click here for Special Testing info

Click here for Spanish Special Testing info

LipiScan:

Yes I do want the LipiScan($30).

No, I do NOT want the LipiScan.

Tear Osmolarity:

Yes I do want the Tear Osmolarity($30).

No, I do NOT want the Tear Osmolarity.

InflammaDry:

Yes I do want the InflammaDry($30).

No, I do NOT want the InflammaDry.