Welcome to Eyes of the World Online Patient Form

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Demographics


Patient Information
TitleFirst*Last*MISuffixNickname
Address:*
City:* State:* ZipCode:*
Home Phone:* Work Phone:
Other Phone: Alerts:
Cell Phone:* Preferred Contact Method:
SSN (last 4 digits) Email
Birthday:* Occupation
Sex:* Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer / School Name
Misc/Guardian
Billing Information Is The Billing Address Different?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

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:Spouse Child Other
Sex: Male Female
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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

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:Spouse Child Other
Sex: Male Female
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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Medical History

Personal & Social History

Referred By:
Has a family member been seen by us? If yes, please give name:
Primary Care Physician:
Hobbies: Employer

Medical & Eye History

What is the main reason for scheduling an appointment today?
If there is a specific issue, please elaborate:

Last Eye Exam: Do you wear glasses?
Do you wear contact lenses? Type of contacts?


Do you or members of your immediate family have any of the following conditions?

 SelfFamilyRelationship
Diabetes:*
High BP:*
Heart Condition:*
Thyroid Condition:*
Asthma:*
Sinus Issues:*
Cancer:*
Glaucoma:*
Lazy Eye:*
Macular Degen:*
Cataracts:*
Other:*

Do you experience flashes of light?*
Do you experience floaters in your vision?*
Have you ever had an eye injury?*
Have you ever had eye surgery?*
Do you frequently have double vision?*
Are you troubled by frequent headaches?*
Are you pregnant/nursing?:*

Are you taking any medications? If no, type 'None':*

Are you allergic to any medications? If no, type 'None':*

Other Health Conditions? If no, type 'None':*

Review of Systems

Please choose from the menu options or select "OTHER" to type your answer. Thank you!

General:* Skin:*
Ears, Nose, Throat:* Neurological:*
Cardiovascular:* Psychiatric:*
Respiratory:* Endocrine:*
Genitourinary: Blood/Lymph:*
Gastrointestinal:* Allergy/Immune:*
Musculoskeletal:*

Dilation/Optomap


Dilation/Optomap Education and Consent

As part of a comprehensive eye examination, it is recommended that ALL patients have the internal health of their eyes
thoroughly evaluated every year. This is performed as either a dilated retinal exam or Optomap retinal imaging.

Our practice is pleased to provide all of our patients with the most highly advanced technology available in retinal
screening today. Our ability to view your internal retinal health is now dramatically improved with the Optomap. We
are among the 5% of eye care providers in the country with this technology.

Dr. Phillips is committed to diagnosing and documenting ocular pathology such as macular degeneration, glaucoma,
retinal detachments
and diabetic retinopathy (all of which can lead to partial loss of vision or blindness). Systemic
diseases such as diabetes and high blood pressure can also be discovered during a retinal exam. Just as your dentist
regularly takes pictures of your teeth, or mammograms are used for early detection, your eyes deserve the same
quality care
. These health conditions are difficult to detect without the Optomap Retinal Exam or without dilation of
the pupils with eye drops due to the limited view of the internal structures of the eye.

The Optomap Retinal Exam:
- Captures a digital scan of the retina in less than a second with no side effects. Fast, easy and comfortable.
- The scans become permanent records that will assist the doctor to monitor and compare any retinal changes annually.
- Gives in depth views of the retinal layers (where disease can start).
- Allows your doctor to review your Optomap retinal image with you.
- DOES NOT require dilating drops which result in blurred vision (especially up close) and sensitivity to light for
   4-5 hours.
Please note: Some patients may need to have their eyes dilated as well.

THERE IS AN ADDITIONAL FEE OF $20.00 FOR THE OPTOMAP RETINAL EXAM WHICH IS NOT COVERED BY INSURANCE.

Please only check one.

I have read and understand the above, and agree to the Optomap Retinal Exam.
I have read and understand the above, and decline the Optomap Retinal Exam but I wish to have my eyes dilated.
I have read and understand the above, and decline both the Optomap Retinal Exam and dilation at this time.

Patient/Parent Signature:* Date:*
    Please type full legal name as electronic signature.

Office Policies


Office Policies

PROFESSIONAL FEES

- Comprehensive examinations paid on day of service are $119. A basic, spherical contact lens evaluation is an additional $45; toric, $55;
   monovision, RGP or bifocal, $65. A contact lens evaluation based on an out-of-office spectacle prescription less than six months old is $75.

- If creating a third party claim, the comprehensive exam fee and refraction are not discounted and are billed at $165.

- Professional fees are non-refundable, but in the rare event that a return or refund is necessary on contact lenses, the following guidelines and
   policies apply:

All contact lens evaluations include follow-up visits, if needed, within 90 days. After 90 days, contact lens follow-ups are $30 per visit.


INSURANCE and PRIVACY POLICY ACKNOWLEDGEMENT

About Your Insurance

There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and Eyes
of the World accepts most insurance plans in both categories:

1) Vision plans such as VSP, EyeMed, Davis Vision, Spectera and others.
2) Medical insurance such as Regence Blue Cross/Blue Shield, PacificSource, Moda, Medicare and others.

- Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care
   (the diagnosis, management or treatment of eye health problems).
- Medical insurance must be used for medical eye care.

If you have both types of insurance plans, it may be necessary for us to bill some services to one plan and some services to the other. We will
follow a procedure called coordination of benefits to do this properly and to minimize your out-of-pocket expense.

Our staff will be happy to bill primary insurance companies, when applicable, as a courtesy to you. Please provide your insurance cards to
staff member so we can make copies for insurance billing purposes. We consider your insurance limitations and benefits as a contract between
you and your insurance company. Even though we have submitted a claim to your insurance, you will be responsible for any portion not paid
by your insurance within 45 days after filing your claim. Our office requests that all insurance co-payments and fees that are applied toward
annual deductible be paid at the time of each visit. For your convenience, we accept payments of cash, personal checks, Visa, MasterCard,
Discover, American Express, and Care Credit. There is a $30 fee for returned checks.

I have read and accept your office policies. I hereby authorize any insurance coverage to be paid directly to Dr. Jerry Phillips, O.D. for
services and goods rendered.

I understand that Eyes of the World and Dr. Jerry Phillips, O.D. are committed to keeping my health information private. By signing below, I
acknowledge that I have been presented a copy of the Notice of Privacy Practices. If I am under 18, I will have a parent or guardian sign for me.

  Patient/Parent Signature:* Date:*
    Please type full legal name as electronic signature.

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