Welcome Back! Name First Last D.O.B MM slash DD slash YYYY AgeSS#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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address Cell PhoneReason 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 Other Interior Issues Glaucoma Macular Degeneration Cataracts Diabetic Retinopathy Other Other Vision Disturbance Variable Vision Sudden Vision Change Cloudy/ Filmy Eye Fatigue Flashes/Floaters Other Other General Health Diabetes Plaquenil Use High Blood Pressure Other 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 MM slash DD slash YYYY Last Physical Exam MM slash DD slash YYYY 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 SignatureAny changes in your health history Are there any medications you are taking? Yes No please listAre you allergic to any medications? Yes No please listMEDICAL INSURANCEInsurance Name Pt. Relationship to insured Member IDPolicy Holder Full Name First Middle Last Policy Holder D.O.B MM slash DD slash YYYY Policy Holder’s SS #VISION INSURANCEInsurance Name Pt. Relationship to insured Member IDPolicy Holder Full Name First Middle Last Policy Holder D.O.B MM slash DD slash YYYY 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.SignatureDate 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. SignatureDate MM slash DD slash YYYY 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.SignatureDate MM slash DD slash YYYY