Welcome Back

Patient First and Last Name:

Patient DOB:

Guarantor First and Last Name (if different than above):

Address (city, state, zip):

e-mail:

Phone (cell):

What is the major purpose of this visit?

Has your vision or medical insurance changed?

Yes

No

New Vision Insurance Company and Phone:

Vision Insurance ID:

Subscriber last 4 of S.S. #:

Subscriber Name:

Subscriber DOB:

New Medical Insurance Company & Phone

Medical Insurance ID:

Subscriber Name (if different than above):

Subscriber DOB (if different than above):

If your vision or medical history has changed, please explain:

Name and Phone Number of Primary Care Physician/Pediatrician

List of current medications:

List of allergies (medicines, seasonal, foods):

During the last week, have you experienced eyes that are sensitive to light:

During the last week, have you experienced eyes that feel gritty:

During the last week, have you experienced painful or sore eyes:

During the last week, have you experienced blurred vision:

During the last week, have you experienced poor vision:

During the last week, have problems with your eyes limited you in reading:

During the last week, have problems with your eyes limited you in driving at night:

During the last week, have problems with your eyes limited you in working with a computer or bank machine (ATM):

During the last week, have problems with your eyes limited you in watching TV:

During the last week, have your eyes felt uncomfortable in windy conditions:

During the last week, have your eyes felt uncomfortable in places or areas with low humidity (very dry):

During the last week, have your eyes felt uncomfortable in areas that are air conditioned:

By entering my name in this field, I agree with and will comply with the Insurance & Fee Responsibility Agreement (see link at the bottom of the page to review Agreement):

Date I signed the Insurance & Fee Responsibility Agreement:

A dilation during a yearly eye exam will NOT check for diabetes, glaucoma, high blood pressure or other specific diseases in the eyes. If you are concerned with diabetes in the eyes or any other specific eye disease, you will need to schedule a separate office visit to investigate those concerns. Routine vision insurance does not provide coverage for the evaluation of eye diseases. Diagnoses will NOT be made.

I decline the general dilation

Go forward with the general dilation

Schedule a separate office visit

COVID-19 Release: Even with increased safety measures, there is an inherent risk of being exposed to COVID-19 whenever you are in a public place and people are present. COVID-19 can lead to severe illness and death. By visiting the office, you assume all risks associated with exposure to COVID-19. By entering my name below, I agree (if the patient is a minor, please have a parent or guardian sign off on this COVID-19 Release).

Date that I signed and consented to the COVID-19 Release as stated directly above: