Patient information

First name

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Last name

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Nickname

Gender

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

Title

First

Last

Middle

Suffix

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Vision Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History:

How Did You Hear About Us?

Last Eye Exam

Primary Care Physician

Average amount of hours per day on screens

Hobbies, occupational needs, or specific visual needs?

What is the main reason for your visit today?

Medications No Medications

Drug Allergies No known drug allergies

Vitamins

Over the Counter Medications

Pregnant or Nursing

Do you have any of these medical conditions?

Diabetes

Year Diabetes Diagnosed

HbA1c

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Do you currently have any of these symptoms?

Please list any eye surgeries and/or trauma (include dates)

Family Eye History

Does anyone in your family have any of these eye conditions?

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STDs

Please read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

CONSENT FOR MEDICAL TREATMENT

I hereby authorize and request that Lookout Eyecare provide such medical care and administer such diagnostic and/or therapeutic procedures and treatments as in the judgment of the optometrist in attendance are deemed necessary and advisable.

Patient Signature

Date

DILATION:

Dilation of the eyes involves the use of eye drop medications to widen your pupil. This allows your doctor to get a better view of the health of the eye, think of this as your ocular health physical. Dilation can cause blurry vision especially up close like on a cell phone or computer. The effects of dilation last from 2-4 hours. Most individuals feel comfortable driving home after, but it is advised to set up a driver for your appointment in the case you would like assistance after your exam. The doctors of Lookout Eyecare require dilation for all patients under the age of 13 years old for a glasses or contact lens exam. It is strongly advised for all patients.

options:

I give permission for my doctor to dilate my eyes to better assess my ocular health. I understand this is also included in my exam and not an additional cost to me.

I give permission to dilate AND include Maestro Retinal Imaging ($40) - This is considered standard of care by Lookout Eyecare doctors.

I am declining dilation at this time.

I am declining dilation and would like to perform Maestro Retinal Imaging ($40)

** I understand the doctor will carefully review any findings or abnormalities during my exam. Dilation may still be necessary per the discretion of the doctor.

If you are declining dilation, please read the statement below:

I understand that the exam performed today will include a refraction status evaluation and an undilated eye exam only. This means that the medical conditions like retinal tears, detachments, masses and other conditions may be missed. My doctor recommends a complete medical eye exam with dilation, but I understand the risks and I am declining.

Patient Signature

Date

Please read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

HIPAA

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which I can access in the link below, that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician certifications. I consent for Lookout Eyecare to communicate with me via unsecured encrypted email. If not, I agree to use the secure HIPAA compliant patient portal upon which a unique username and password will be provided to me.

View Notice of Privacy Practices Form

Patient Signature

Date

INSURANCE COPAY & DEDUCTIBLES

Routine eye wellness exams will be billed to your vision insurance plan and patient responsibility for routine exam or materials copays and coinsurance is due at the time of visit. However, if you have medical conditions, have medical testing, or the doctor uncovers a medical diagnosis as the cause of your presenting symptoms, the exam and/or any associated medical procedures must be billed to your medical insurance carrier. I acknowledge for any visit that I will assume full financial responsibility for services rendered to me if my insurance carrier denies or does not cover my claim for these services.

I understand that I am responsible to pay all co-payments at the time of service. Co-payments cannot be waived at any time by the provider of service or Lookout Eyecare. If my insurance determines that I have not met my deductible, I understand that I will be fully responsible for payment in a timely manner, no more than 30 days after I have been notified by insurance and/or provider. Yearly deductibles cannot be waived at any time by Lookout Eyecare.

I hereby understand and fully agree with office policies ,charges and protocols.

* If patient is a minor: I attest that I am the legal guardian with legal authority to make medical decisions for this minor:

Name of Legal Guardian

Guardian Signature