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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SSN

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Occupation

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Gender

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Billing information

Is The Billing Address Different? Yes

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Title

First

Last

Middle

Address:

City:

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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

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

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

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

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Last Eye Exam

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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

Unknown Family History

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

Hypertension

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

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

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

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

HIPAA Consent and Payment Authorization

Click Here To View HIPAA Document

I hereby authorize Dr. Kristine-Hue Van & Associates, Inc. to obtain my medical information to assist in the care of my health. This information may be disclosed and used to carry out my treatment, to obtain payment from insurance companies, and for health care corporations like quality reviews. I have been offered a copy of the clinic's Privacy Notice for a more complete description of uses and disclosures before signing this consent. I understand that this clinic has the right to change their privacy practices and that I may obtain any revised notices from this clinic. I understand that I have a right to request a restriction of how my protected health information is used. I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed. I authorize any necessary medical treatment by the optometrist in this clinic. I further authorize this clinic to release or obtain any required medical information from my attending physicians or any medical facility.

Your insurance is meant to serve as a financial aid. We are happy to take assignment on your benefits. If you are not eligible for these benefits or are eligible for less than full coverage, your signature indicates that you agree to be financially responsible for the balance not paid by your plan. Our office staff will make every effort to verify benefits for you. VERIFICATION OF BENEFITS IS NOT A GUARANTEE OF PAYMENT. I am aware that I have 90 days from the date of service to finalize my contact lens prescription or for a spectacle prescription check without a charge. Payment for exam fees are due at the time of service. Insurance information must be presented before services are rendered. Professional fees cannot be refunded. I agree to pay any balances not covered by my insurance within 30 days. We are requiring a credit card on file at the time of service. Your credit card will be stored in a HIPAA compliant credit card system. Your card will be charged in the following manners such as: exam co-pays, co-insurance amount, out of pocket payments, deductibles, no shows or late cancellation fee of $30.00 and any balances that was not covered by your insurance. Your card will be charged and you will be notified by text, email or a phone call of the charges.

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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Signature

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