Name

First Last

D.O.B

Age

SS#

Is the address on your driver’s license your current address?

Yes
No

please provide your current address below

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address

Cell Phone

Reason for today’s visit: Please choose between #1or #2 (Fees vary according to level of service)

Please check all that apply
#1 : Medical Eye Examination: for medical eye problems or an annual diabetic exam. (Billable to medical insurance)
Please check all that apply

*Refraction (prescription measurement) usually not covered by most medical insurances*
Additional $40.00

Exterior Discomfort

Dryness
Burning
Itching
Watering
Eyelid Problem
Other

Interior Issues

Glaucoma
Macular Degeneration
Cataracts
Diabetic Retinopathy
Other

Vision Disturbance

Variable Vision
Sudden Vision Change
Cloudy/ Filmy
Eye Fatigue
Flashes/Floaters
Other

General Health

Diabetes
Plaquenil Use
High Blood Pressure
Other

#2 : Annual Eye Wellness Exam: For vision needs (eyeglasses and/or contact lenses) and eye health screening.(Billable to vision insurance)

Are you interested in getting contacts today?

A contact lens fitting is required for a contact lens prescription in order to renew your annual contact lens prescription, even if your vision has not changed. This is a separate charge from the eye exam.
VISION INSURANCE MAY NOT COVER THIS FITTING FEE.

Last Eye Exam

Last Physical Exam

In order to examine the eye, we must dilate the pupil or take an Optomap image of the retina. Dilating drops enlarge the size of the pupil allowing the doctor a more thorough examination of your retina for eye diseases such as cataracts, glaucoma,retina detachment, hypertension, diabetes etc. You may have blurry vision for 2-5 hours and light sensitivity. The Optomap camera allows a view without dilation in most cases for an additional charge.

Which method of ocular health evaluation do you prefer?

Optomap (additional $39)
Dilation

Signature

Any changes in your health history

Are there any medications you are taking?

Yes
No

please list

Are you allergic to any medications?

Yes
No

please list

MEDICAL INSURANCE

Insurance Name

Pt. Relationship to insured

Member ID

Policy Holder Full Name

First Middle Last

Policy Holder D.O.B

Policy Holder’s SS #

VISION INSURANCE

Insurance Name

Pt. Relationship to insured

Member ID

Policy Holder Full Name

First Middle Last

Policy Holder D.O.B

Policy Holder’s SS #

I acknowledge that if my insurance does not cover the procedure and/or materials I will be held responsible for the unpaid balance.

Signature

Date
MM slash DD slash YYYY

ACKNOWLEDGMENT OF HIPPA:

I acknowledge that I have read and understand a copy of Strong Vision Center, P.A. Notice of Privacy Practices.

Signature

Date

Authorization for Release of Information to Family Members

Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below. I authorize Strong Vision Center to release my medical and/or billing information to the following individual(s):

1

Relation to Patient

2

Relation to Patient

3

Relation to Patient

NO ONE

I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that the information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient. You have the right to revoke this consent in writing.

Signature

Date

Welcome Back!

Reason for today’s visit: Please choose between #1or #2 (Fees vary according to level of service)

VISION INSURANCE MAY NOT COVER THIS FITTING FEE.

MEDICAL INSURANCE

VISION INSURANCE

ACKNOWLEDGMENT OF HIPPA:

Authorization for Release of Information to Family Members

Strong Vision Center Fairfield

Strong Vision Center