ONLINE WELCOME FORM

 

Please take a few minutes to complete this Patient Welcome Form before you visit our office for the first time. Once you fill in the information, click on the "Submit" button to e-mail it to our office.

 

NEW PATIENTS, please fill out the entire form.

RETURNING PATIENTS, please fill out the blue shaded sections only.

 

Complete Your Personal Information

Salutation

Mr. Mrs. Ms. Dr. Miss. Master Rev.

First Name*

     

MI

     

Last Name*

     

 

Preferred Name

     

 

Address

     

City

     

State

     

Zip

     

Home Phone

     

Work Phone

     

 

 

Phone Ext.:

     

Email Address*

     

Date of Birth (MM/DD/YYYY)*

     

Patient's Gender

Male Female

Height in Feet:    

Height in Inches:    

Height in CM:    

Height Units: ft in cm m

Weight :      

Weight Units : lbs kg

Race :

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White Native American Caucasian Refuse to Specify Not Disclosed Other Race

Ethnicity : Hispanic or Latino Not Hispanic or Latino Unknown

Spouse/Parent Name

     

Guardian

     

Emergency Contact Name

     

Emergency Contact Number

     

How Found

Phone Book

School

Ad

Previous Patient

 

Insurance Listing

Drive By

Other

Doctor

Referred By

     

Pharmacy

     

Pharmacy Address

     

Complete Your Primary Care Physician

First Name

     

MI

     

Last Name

     

 

Clinic Name

     

 

Address

     

City

     

State

     

Zip

     

Phone Number

     

 

 

Complete Your Referring Physician

First Name

     

MI

     

Last Name

     

 

Clinic Name

     

 

Address

     

City

     

State

     

Zip

     

Phone Number

     

 

 

CONTACT LENS MEDICAL EXAM

 

If you wear contact lenses or wish to try contact lenses, your insurance plan may not cover the contact lens portion of your exam. The Contact Lens Medical Exam (CLME) is a fee in addition to the Comprehensive Eye Examination. The fee for a CLME can range from a level 0 at $52.74 to Level 5 at $264.71 or higher for complex or custom lenses. The level is determined by your doctor at the time of your exam.

 

Yes No By checking YES to this statement, I am indicating that I am aware of and responsible for this charge.

 

Email Communication

We will use your email address to send appointment reminders and other non-private correspondence. We will not share or sell your email address.

Recalls

We will send recall notices reminding patients when they are due to schedule and appointment via postcard and email.

 

Pharmacy Data

With the name of your pharmacy and our electronic prescribing software, we have the ability to access your current prescribed medications for our records. It is important to know what medications patients are taking for the following reasons: Many medications may have ocular side effects, the conditions related to these medications may have ocular manifestations, and certain prescribed medications can interact with other medications. Indicate we have permission to access your medication list.

 

Yes No

 

iWELLNESS EXAM

 

We recommend the iWellness Exam to all of our patients. This consists of an Optomap Scan (a digital image of the retina) and a high speed OCT scan (reveals ocular anatomy and pathology). Together, these scans enable us to more thoroughly evaluate you for vision threatening conditions. The iWellness Exam is only $59 and is typically not covered by insurance. In most cases, it can be submitted to your FSA or HSA accounts.

 

Yes No By checking YES to this statement, I am indicating that I am aware of and responsible for this charge.

 

NEW PATIENTS please continue and fill out all the remaining pages. Please remember to hit the submit button.

 

RETURNING PATIENTS, thank you for completing this information. Please scroll down to the end of the form and hit the submit button.

 

Complete Your Health History

Main Reason for Exam?

     

 

Last Exam Date? (MM/DD/YYYY)

     

 

When was your last health exam?

     

 

Enter past illnesses or injuries

     

     

Past Surgeries?

     

     

Please list all medications or provide a list to the doctor

 

     

     

 

     

     

Please list all eye drops you are currently using

 

     

     

 

     

     

Please list any reactions or sensitivities you have experienced

     

Please list any specific allergies

     

 

Complete Your Eye History

Glaucoma

Yes

No

Infection of Lid

Yes

No

Cataract

Yes

No

Itching

Yes

No

Macular Degeneration

Yes

No

Mucous Discharge

Yes

No

Retinal Detachment

Yes

No

Drooping Eyelid

Yes

No

Color Blindness

Yes

No

Redness

Yes

No

Headaches

Yes

No

Sandy or Gritty Feeling

Yes

No

Glare/Light Sensitivity

Yes

No

Blurred Vision Distance

Yes

No

Tired Eyes

Yes

No

Blurred Vision Near

Yes

No

Lazy Eyes

Yes

No

Crossed Eyes

Yes

No

Burning

Yes

No

Distorted Vision (halos)

Yes

No

Dryness

Yes

No

Double Vision

Yes

No

Excess Tearing/Watering

Yes

No

Floaters or Spots

Yes

No

Eye Pain or Soreness

Yes

No

Fluctuating Vision

Yes

No

Foreign Body Sensation

Yes

No

Loss of Vision

Yes

No

Loss of Side Vision

Yes

No

 

 

 

 

Complete Your General Health Condition

Fever

Yes

No

Muscles/Bones/Joints

Yes

No

Weight Loss

Yes

No

Skin

Yes

No

Other Symptoms

Yes

No

Neurological
(i.e. Multiple Sclerosis)

Yes

No

Ears/Nose/Throat

Yes

No

Anxiety or Depression

Yes

No

Heart conditions
(i.e. high blood pressure)

Yes

No

Thyroid/Diabetes

Yes

No

Respiratory (i.e. Asthma)

Yes

No

Blood/Lymph (cholesterol)

Yes

No

Gastrointestinal

Yes

No

Allergic

Yes

No

Kidney

Yes

No

 

 

 

Are you?

Pregnant Nursing

 

Complete Your Family History

Amblyopia (Lazy Eye)

Yes

No

Cancer

Yes

No

Blindness

Yes

No

Diabetes

Yes

No

Cataract(s)

Yes

No

Heart Disease

Yes

No

Color Blindness

Yes

No

High Blood Pressure

Yes

No

Glaucoma

Yes

No

Kidney Disease

Yes

No

Macular Degeneration

Yes

No

Lupus

Yes

No

Retinal Detachment

Yes

No

Stroke

Yes

No

Strabismus (i.e. Eye Turn)

Yes

No

Thyroid Disease

Yes

No

Arthritis

Yes

No

Others

Yes

No

Complete Your Spectacle Lens History

Do you use a computer?

Yes

No

How many hours/day?

     

Distance from Computer?

     

Do you drive?

Yes

No

Mileage to work each way?

     

Do you have glare problems?

Yes

No

Do you have visual difficulty when driving?

Yes

No

Do you have problems with night vision?

Yes

No

Do you currently wear glasses?

Yes

No

Since?

     

Type of glasses?

Full Time Part Time Distance Close

Glasses Owned?

SingleVision

Bifocals

Trifocals

Backup Glasses

 

Safety

Sports

Progressive

Have you had trouble with glasses in the past?

Yes

No

Reason:

     

Do you wear sunglasses?

Yes

No

Are your sunglasses your current prescription?

Yes

No

Special eyewear needs?

Computer (special prescriptions, special anti-glare tints or coatings)

 

Occupational (mechanics, plumbers, pilots)

 

Safety Glasses (gardening, woodworking, welding)

 

Sports/Hobbies (racquet sports, motorcycle)

Complete Your Contact Lens History

Do you currently wear contact lenses?

Yes No

Since?      

If not a contact lens wearer, are you interested in trying contact lenses at this time?

Yes

No

Have you ever tried to wear contacts?

Yes

No

 

If yes, what was the reason for stopping?

     

Type and brand of contacts?

     

 

Today's wearing time?

     

 

How many hours/day?

     

 

How many days/week?

     

 

 

Please rate the following on a scale of 1-10 with 1 being POOR and 10 being EXCELLENT.

Lens Comfort

Right

     

Left

     

Distance Vision

Right

     

Left

     

Near Vision

Right

     

Left

     

What solutions do you use?

     

 

Disinfectant used?

     

 

Enzyme used?

     

 

 

Complete Your Social History

Current occupation

     

Years?

     

Employer Name

     

Do you use nutritional supplements (vitamins etc.)?

Yes

No

 

Do you engage in regular exercise?

Yes

No

 

Do you drink alcohol? If yes - how often?

No

Occasional

1 per day

 

2-3/day

4+/day

 

Do you smoke? If yes - how much/often

No

Occasional

1/2 pack/day

 

1 pack/day

1+ pack

 

Method of Tobacco Intake?

Smoking

Chewing

 

Do you use Illegal Drugs?

Yes

No

 

List your hobbies

     

 

We reserve the right to charge for missed appointments. Payment is due in full at the time professional services are provided. By SIGNING BELOW, I ACKNOWLEDGE THAT I AM RESPONSIBLE TO REMIT PAYMENT FOR THESE SERVCES. Virginia Eyecare Center, P.C. accepts cash, checks, MasterCard, Visa, AMEX and Discover credit cards. If payment in full is not received within 30 days from the due date by us, finance charges shall accrue at the rate of 1.5% per month on the unpaid balance. This charge will be added to my account every 30 days thereafter that the balance remains unpaid. Additionally, if Virginia Eyecare Center, P.C. should collect the amount due through the courts of the commonwealth of Virginia, I also agree to pay its court costs and reasonable attorney's fees. You agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt, and all costs, and expenses, including reasonable attorneys fees, we incur in such collection efforts. If my check is returned to Virginia Eyecare Center, P.C. for any reason, I will pay an additional service charge. If I have eyecare insurance, Virginia Eyecare P.C. may, as a courtesy, verify my benefits and submit the forms necessary for insurance payment. However, I understand that verification does not guarantee payment by the insurance company or release me of legal obligation to pay for the services provided. As a subscriber, I am responsible for knowing the benefits & limitations of my particular plan. It is my responsibility to provide Virginia Eyecare Center, P.C. with the appropriate referral forms & associated information for any services that require such forms. It is my responsibility to pay for any claims that are unpaid or denied. My signature indicates I have read & agreed to the policies read above. It also indicates that I am aware of Virginia Eyecare Center, P.C.' Notice of Privacy Practices.'

 

Thank you for completing this form. We look forward to seeing you.

 

Electronic Signature:       Date:      


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