Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

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Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

Race

Ethnicity

Preferred Language

Billing information

Is The Billing Address Different? Yes

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Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Medical History

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Eye History

Primary Reason

Additional Reason For Visit

Last Eye Exam

Current Vision Correction

Have you been diagnosed with any of the following conditions?

What eye medications / eye drops do you use?

Have you had any eye surgery (cataract surgery, Lasik, etc)? Please describe.

Have you had any eye injuries? Please describe

Contact Lens Wearers only:

Brand Of Contacts worn in the past

Cleaning Solution

How often do you discard your lenses?

How often do you wear lenses?

Family Eye History

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

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Medical History:

Current Medications

Allergies To Medications

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Pregnant or Nursing

Review Of Systems

General

Ear/Nose/Throat

Cardiovascular

Respiratory

Genitourinary

Musculoskeletal

Gastrointestinal

Skin

Neurological

Psychiatric

Endocrine

Blood/Lymph

Immune

Family Medical History

Unknown Family History

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

Hypertension

Diabetes

Cancer

Heart Conditions

Other

Social History

Hobbies

Smoking Status

Alcohol Use

Illegal Drug Use

Policies, Consent, Submit Data

Optomap Digital Retinal Imaging and Dilation:

In order to rule out and/or monitor many eye diseases, the internal structures of your eyes need to be evaluated. This can be accomplished with retinal imaging or with dilation eyedrops.

Optomap Digital Retinal Imaging (Doctor's recommendation)

This advanced technology allows us to take a 200-degree high resolution image of the retina in a single snapshot without any side effects. It serves as a permanent part of your record and will be reviewed with you in the exam room. These images are a great way to track the health of your eyes over time. Your copay is $35.

Pupil Dilation

Dilation eyedrops take 20-30 minutes to work and will lengthen your visit by 30-45 minutes. Side effects include blurred vision, light sensitivity, difficulty reading and looking at digital devices, and will last 4-6 hours. **Please note there may be situations where both images and dilation are indicated. This will be determined by the doctor during your eye exam and discussed with you.

Financial Consent and Insurance Authorization:

I understand that professional fees are due upon completion of the exam and are nonrefundable. I understand that glasses are a custom-made item and thus all glasses purchases are nonrefundable. Boxes of contact lenses may be returned for a refund within 90 days as long as the boxes are unopened and in original condition without writing on or damage to the boxes. I understand that it is my responsibility to know my insurance coverages and that I am responsible for all copays, deductibles, and other balances not covered by my insurance. I consent to Now Eye See Vision Care releasing all information necessary to secure payment from my insurance carrier. I understand that authorizations from my insurance carrier do not guarantee payment, and that I am responsible for denied claims.

Patient Signature (Please type your first and last name)

Date

HIPAA Acknowledgment:

Click here to view our HIPAA Notice of Privacy Practices. I have reviewed the HIPAA Notice of Privacy Practices, understand that I have an opportunity to discuss my right to privacy, and know that upon request I will be given a copy of the notice.

Patient Signature (Please type your first and last name)

Date

Contact Lens Policy:

There are additional fees for a contact lens evaluation that vary based on type of lenses prescribed. Contact lenses are a medical device and require expert fitting and careful instruction, as well as conscientious care and compliance with the recommended follow-up examinations to maintain the healthy function of your eyes.

All contact lens evaluation fees are non-refundable. Payment of these fees are due at the time of service.

A comprehensive eye examination is necessary to evaluate for contact lens wear and will always be done in conjunction with a contact lens evaluation. 90 days of follow-up care is included in the contact lens evaluation fee to ensure that you like the brand and powers of your new lenses.

If you have never worn contact lenses before, your fee will also include up to 2 one hour training sessions where you will receive instruction on how to insert, remove, clean, and care for the contact lenses. A new contact lenses wearer must successfully complete a training session before they will be allowed to take contact lenses home.

Arizona state law dictates that contact lens prescriptions expire after one year, so yearly examinations are required to maintain an active prescription.

Contact lens prescriptions are uploaded to your patient portal once finalized. Printed copies are available upon request.

I have reviewed, understand, and agree to the Contact Lens Policy.