Online Patient Form

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Patient Information
Address*: Apt/Suite #:
City*: State*: ZipCode*:
Home Phone*: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN (Last 4)* Email*
Birthday* Occupation
Sex Employment Status
Marital Status Employer / School Name
Billing Information Is The Billing Address the Same?

Home Phone:
Work Phone:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Reason for Visit: Secondary Reasons:

Medications: No Meds Used Over The Counter Medications:
Vitamins: Drug Allergies: No Known Drug Allergies
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot:

Family Medical History

Unknown family history

Diabetes: Type: Year Diagnosed: HbA1C:
High Blood Pressure: Describe:
High Cholesterol: Describe:
Thyroid Disease: Describe:
Heart Problems: Describe:
Cancer: Describe:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time: Days per week worn: Hours per day worn:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:

Social History

Hobbies: STD's:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:

Submit Data

Vision Source Austin
Dr. Diane L. Yu-Davis, O.D.

***We would like to have more than one contact method on record for our patients. We will not spam your email. Your email
address will be used to contact you in the event that we cannot reach you by phone. Email is a reliable way to reach us as
well, is monitored even when our office is closed.

When your glasses or contacts arrive can we contact you via: Text message Email

Additional Tests
Please INITIAL on the line next to your preference, and SIGN the line at the bottom of this form. If you have any
questions about the procedures mentioned below, please ask Dr. Diane Yu-Davis.
Your medical insurance may cover the additional tests below (covered completely or with a copay).

Contact Lens Exam ***separate from a Glasses Exam
Yes No        Would you like to renew your contact lens prescription at this time?
                                                         An additional fitting fee is required.

Peripheral Vision Testing
Yes No        Visual Field: no charge- Peripheral vision testing that can detect vision loss due to disease.

Dilation or Optomap Testing
            -  Dilation and the Optomap test allow the doctor to obtain a larger view of internal ocular structures, thus allowing a
               more thorough evaluation of the health of your eyes. Without these tests, the doctor will only be able to examine
               30% of your retina, and may not be able to detect certain diseases that can cause permanent vision loss. The
               most blinding diseases usually do not have warning symptoms such as pain or vision loss. A preemptive test could
               save your sight.
            -  The Optomap is retinal imaging that replaces the need for dilation in most cases. The doctor recommends
               acquiring a baseline image of the eye via Optomap for accurate monitoring and earlier disease detection. It does
               not cause blurry vision or any light sensitivity.

Patient Signature: Date:

Patient Bill of Rights

Thank you for choosing Vision Source to care for your vision! Our goal is to provide comprehensive eye exams with quality
care, service, and professionalism, before, during, and after your exam.. Please read OFFICE POLICIES carefully and let us know if you have any questions or concerns.

            - Payment is due at time of service.
            - Glasses or contacts will NOT be ordered until payment is made in FULL.
            - In the case of non-payment by your insurance carrier, the patient assumes full responsibility for any unpaid               balance.
            - We accept all major credit cards, cash, and checks with proper identification.
            - Eye exam,special testing, contact lens fitting, materials including glasses and contact lens , are NONREFUNDABLE.
            - After your vision and/or medical insurance has been billed and submitted; the fees and payments cannot be refunded or               transferred to another insurance.
            - I give Diane Yu Davis permission to contact me by Text/Personal Email which will contain personal and private               information.
Glasses (Including Frames and Lenses)
            - Please select your frame carefully. Once the prescription lenses are cut for your selected frame, we can change the               frame, but it would be at your expense.
            - If you decide to purchase new lenses for your own, older frames, you do so AT YOUR OWN RISK. Our office will               not refund or replace your used frames should any damage or breakage occur.
            - You have 30 days from the time of pick-up to report any problems with the prescription, such as blurred vision, non-               adaptation, etc. After 30 days, if you report any vision problems with your prescription, you will be charged an office               visit fee. So please allow yourself time to report any problems with the glasses.
            - Should you want to exchange or refund your selected eyewear, you will be responsible for any financial expenses               incurred by Vision Source regarding your order. It is difficult to cancel an order without incurring some, if not all, of               the original charges.
            - When your glasses are ready for pick-up, we will contact you by phone. We ask that you pick them up within 90 days               of our first notification. Any materials not picked up after 90 days will be returned to stock. We will not refund               any collected fees.
            - Most Frames have a year warranty that covers manufacturer defects. This warranty does not extend to damage due to               frame negligence. Lenses purchased without a scratch warranty will be replaced at your expense if damages to the               lenses occur. There is a $20 processing fee per frame and pair of lenses replaced under warranty.
            - Standard plastic and glass lenses can shatter in a high impact situation and cause damage to your eyes and face.               Polycarbonate lenses are recommended for active patients and children under 18 years of age. If you decline               polycarbonate lenses, our office will not be held responsible for any damage to the eye due to breakage or shattering.               
Contact Lenses
            - Trial lenses are dispensed to ensure that the contact lenses are the right fit for the patient. It is important to inform               the doctors of any discomfort or problems within 60 days or you will be charged for an office visit. Once boxes               of contact lenses are dispensed, contact lenses will only be exchanged if the boxes of lenses are returned unopened               and undamaged.
            - When your contact lenses are ready for pick-up, we will contact you by phone. We ask that you pick them up within 90             - days of our first notification. Any materials not picked up after 90 days will be returned to stock. We will not             - refund any collected fees.

Please sign below to indicate that you have read and understood the above policies.

Patient Signature: Date:

Would you like a copy of this form? Yes No

Signature of parent or guardian (if patient is under 18 years of age):

I authorize the release of medical records to myself and to my doctor listed below.

Doctor's Name:
Phone Number:
Fax Number: