Online Patient Forms

Patient Information

Title

First Name

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Last Name

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Nickname

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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Last 4 of SSN

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Occupation

Birth Sex

Male Female

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Billing Information

Is The Billing Address Different?

Yes

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Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

Primary Vision Insurance

Please upload a photo of the front and the back of your Vision insurance card

Front of the ins card:
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Back of the ins card:
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Primary Medical Insurance

Please upload a photo of the front and the back of your Medical insurance card

Front of the ins card:
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Back of the ins card:
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OPTOS RETINAL IMAGING, OPTICAL COHERENT TOMOGRAPHY & MEIBOGRAPHY

We are proud to provide our patients with the state of the art digital scanning technology to have the best possible standard of care. These technologies allow our Healthcare professionals the ability to detect, diagnose, treat and manage various eye diseases including, but not limited to: Glaucoma, Macular degeneration, Diabetic retinopathy, Hypertensive retinopathy, Melanomas and Dry eye disease. Our Healthcare professionals require that all patients have a thorough examination of their retina each year.

• The OPTOS retinal imaging camera can be performed on dilated or non-dilated patients. It allows you the opportunity to see inside of your eyes just as the doctor sees it.

• Optical coherent tomography (OCT) is an imaging technique that uses coherent light to capture very high resolution 2 and 3-dimensional images of the retina.

• The Meibography is an imaging technology that allows us to evaluate the structures of the meibomian glands to detect dry eye disease.

OPTOS Retinal Imaging $39.00

*One Of These field's are required

OPTOS and Dry Eye Screening $49.00

*One Of These field's are required

Wellness Scan (OPTOS + OCT) $55.00

*One Of These field's are required

Wellness Scan Plus (OPTOS + OCT + Meibography) $65.00

*One Of These field's are required

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

Medical History

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Eye History

Type of Visit

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Reason for Visit

Have you had any eye surgeries? Please describe No Eye Surgeries

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Last Eye Exam

By Doctor

Are you under the care of an Ophthalmogist, if so, what is their name?

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Are you interested in contacts?

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications No Medications

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Drug allergies

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Please Describe any Injuries or Surgeries you have had

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Primary Care Physician

Last Health Physical

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Pregnant or Nursing

Do you have any of these medical conditions?

Diabetes

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Hypertension

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High Cholesterol

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Thyroid Conditions

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Heart Conditions

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Cancer

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Family Medical History

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

Unknown Family History

Hypertension

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

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

Unknown Family Eye History

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems (Self)

Do you have any of these medical conditions?

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

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Type

How long

Policies, Consent, Submit Data

Please review the following agreement. Sign below to acknowledge and attach your signature to the final PDF.

Payment Authorization
I have read and agree to the above Payment Authorization Policy

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Health Information Protection
I have read and agree to the Privacy Policy

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Patient Communication
I allow Willow Lawn Eye Care to contact me through text message. I am aware that my information is not shared with third parties for marketing purposes.

I agree

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