DATE:*

NEW PATIENT REGISTRATION FORM

PREFIX: Mr.Mrs.Miss.Dr.

LAST NAME:* FIRST NAME:* MIDDLE INITIAL (OPTIONAL): JRSR

PREFERRED NAME:*

ADDRESS:*

CITY:* STATE:* ZIP:*

HOME#:

CELL#:*

WORK#:

EMAIL:*

BEST WAY TO CONTACT: Cell#Work#Text#Email#

EMERGENCY CONTACT/RELATIONSHIP (optional):

PHONE NUMBER (optional):

EMPLOYER/SCHOOL: OCCUPATION/GRADE:

PATIENT SSN (optional):

DATE OF BIRTH:*

GENDER: MaleFemale

(IF A MINOR) PARENT'S NAME:

SPOUSE'S NAME:

ARE YOU:* MARRIEDSINGLEDIVORCEDWIDOWEDSEPARATED

WHO MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?

Friend or Relative Name:

Another DoctorInsuranceSaw Sign/BuildingNewspaper/Radio/TVWebsite

Online Search. if yes, where did you find us?

Other:

VISION PLAN INFORMATION

VISION PLAN (CIRCLE): VSP DAVIS SPECTERA EYEMED OTHER:*

SUBSCRIBER SSN/ID#:*

SUBSCRIBER NAME:*

SUBSCRIBER BIRTH DATE:*

RELATIONSHIP TO PATIENT:*

MEDICAL INSURANCE INFORMATION

PRIMARY MEDICAL INSURANCE:*

SUBSCRIBER SSN/ID#:*

SUBSCRIBER NAME:*

SUBSCRIBER BIRTH DATE:

SECONDARY MEDICAL INSURANCE? YesNo

SECONDARY MEDICAL INSURANCE:

SUBSCRIBER SSN/ID#:

SUBSCRIBER NAME:

SUBSCRIBER BIRTH DATE:

I participate in a Flex-spending AccountI have Care Credit

LIFESTYLE QUESTIONS (check all that apply)

I use digital devices/computer on a regular basis? If yes, how many hours per day? hrs/day?

I spend time/work outdoors? How often? hrs/day?

I participate in vision-related sports or other activities?I participate in activities that may put your eyes in danger?I plan on purchasing eyeglasses at my visit?I want thinner/lighter lenses?I prefer NOT to wear glasses at times?I have prescription sunglasses?My eyes are very sensitive to sunlight/bright light?I have more than 1 pair of current prescription glasses?I am interested in Laser Vision CorrectionI have family members in need of eyecare.

CONTACT LENS INFO:

Do you wear contact lenses? YesNo TYPE/BRAND:

Interested in contact lenses? YesNo

FINANCIAL INFORMATION

In order to control the cost of billing, we ask that the patient’s portion is paid at the time services are rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge of $25 on all returned checks. Payment from my vision plan/medical insurance is to be paid directly to Clearfinity Eyecare Optometrist and I understand that (name of vision plan or medical insurance) will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made once the claim is processed. All eyewear purchases are final sale and only a store credit can be issued that can be used for any future eyewear purchases.

PRIVACY PRACTICES

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree you are bound to abide by such restrictions.

DATE:*

PATIENT NAME:*

PATIENT MEDICAL HISTORY

FAMILY PHYSICIAN:

ADDRESS:

LAST PHYSICAL CHECK-UP:

CURRENT MEDICATIONS (PRESCRIPTION OR OVER-THE-COUNTER)

ALLERGIES TO MEDICINES? YesNo

IF SO, WHAT MEDICATIONS?

DO YOU USE CIGARS/ CIGARETTES/ TOBACCO? YesNo

DO YOU DRINK ALCOHOL? YesNo

DO YOU USE RECREATIONAL SUBSTANCES? YesNo

HAVE YOU EVER BEEN DIAGNOSED OR TREATED FOR THE FOLLOWING?

Allergies YesNo

Arthritis YesNo

Sickle Cell YesNo

Bronchitis YesNo

Cancer YesNo

Cholesterol YesNo

Diabetes YesNo

Digestive YesNo

Autism YesNo

Multiple Sclerosis YesNo

Eczema/Rashes YesNo

ADHD YesNo

Vascular Disease/Stroke YesNo

Heart Disease YesNo

High Blood Pressure YesNo

Seizures YesNo

Kidney disease/Stone YesNo

Autoimmune Disease YesNo

Migraines YesNo

Psychiatric YesNo

Asthma/Lung disease YesNo

Sinus/Throat Infections YesNo

Thyroid Disease YesNo

Unusual weight losses/gains YesNo

PATIENT NAME:

PATIENT EYE HISTORY

Date of Last Eye Exam:

By Whom?

Have you had any eye-related surgeries of any kind? YesNo

WHAT ARE THE MAIN REASON (S) FOR YOUR VISIT? (Check all that apply)

Distance Blurred VisionNear Blurred VisionSudden loss of visionSeeing Flashes/FloatersContact lens DiscomfortEye itching/allergiesCrossed eye/Eye turnDouble VisionDry/Burning EyesTearing/watering eyesDischarge from EyesForeign matter in eyesUnusual light sensitivityFrequent headachesComputer EyestrainInterest in LASIK/PRKEye pain/soreness

Other:

CHECK EYE CONDITIONS THAT YOU HAVE BEEN DIAGNOSED:

Macular DegenerationDry Eye/AllergiesRetinal DetachmentEye injury/surgeryCataractsGlaucomaOther:

FAMILY HISTORY: Relationship (Mother/Father/Sister/Brother/Grandparent)

Blindness

Cataracts

Keratoconus

Diabetes

Glaucoma

Heart Disease

Lazy Eye

Macular Degen

Retinal Detachment

ABOUT YOUR VISION PLAN/MEDICAL INSURANCE

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts one or both:

• Vision Care Plans (such as VSP, Davis, Eyemed etc..)
• Medical Insurance (such as Blue Cross/Blue Shield and United Health Care etc..)
• Vision care plans ONLY cover ROUTINE vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They DO NOT cover diagnosis, management, or treatment of eye diseases, dry eye, itchy eyes, cataracts etc...
• Medical insurance MUST be used if you have any eye health problem or systemic health problem that has ocular complications. (e.g. dry eye, red eye, eye pain, itchy eyes, discharge from eyes etc..) Your doctor will determine if these conditions apply to you, but some are determined by your case history or reason for your visit.
• If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.
• We will bill your insurance plan for services if you we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract.

I have read and agree with these policies:

Date:

ADDITIONAL EYE HEALTH SCREENINGS

A Routine Eye Exam is focused on assessing and maximizing vision along with a general health assessment of your eyes. However, there is additional state-of-the-art technology, beyond just dilating your eyes, that we offer that can allow for a more thorough evaluation that can uncover any EARLY signs that may be missed until TOO LATE.

Ocular Coherence Tomography (OCT) is an advanced eye scan that uses light to illustrate the different layers that make up the back of the eye – like assessing the inner layers of a sandwich beyond the bread. A detailed 3D image below the surface of your retina is produced, giving the doctor a deeper, detailed picture of your eye health. The scan is non-invasive, painless, simple and quick.

It can help the doctor measure and monitor for any early retinal tissue, macula, or optic nerve disease. It can mathematically show any changes from one visit to the next.

This image is stored on our computer and in your electronic health record giving you an invaluable continuous record of the health and condition of your eyes.

What can the scan check for?

Common conditions identified through regular OCT screening: - Early Age Related Macular Degeneration

• Early Glaucoma
• Diabetes Retinopathy
• Macular Holes/Edema

A Wellness Retinal imaging Screening allows the doctor to look at a magnified view of the retinal and optic nerve tissue (the bread of a sandwich). This allows the doctor to catch very small defects that may be missed looking at a moving eye ball and can track for any changes in the appearance of the retina over time.

The Visual Field Screening is an interactive test that allows the doctor to check the actual function of the visual system from the optic nerve to the brain (the part the doctor cannot see).

The OCT, Retinal Imaging, and Visual Field Screenings are additional tests that are not part of a normal eye exam. All screening program/tests are NOT COVERED BY MEDICAL INSURANCE.

All three screenings together help the doctor to get a COMPLETE PICTURE/FUNCTION of your EYE HEALTH and identify possible issues that may be missed and is strongly recommended. If any abnormalities are found you will be scheduled for a medical evaluation and a more extensive testing program will be implemented to dive deeper into the issue. Please select the following:

YES. I would like to have the Retinal Imaging, Visual Field, and OCT Screenings for $99YES. I would like to have Retinal Imaging and Visual Field Screenings for $59YES. I would like to have OCT Screening only for $49.NO. I do not wish to do any additional screening of my eyes today.

CONTACT LENS EVALUATION FEE

According to the FDA, all contact lenses are considered a MEDICAL DEVICES, since they are inserted directly on your eyes. Therefore, every year, if you want to purchase contacts or get a prescription for them, even if your prescription does not change, you must get a new evaluation for eye health purposes. This fee is separate from your regular exam that includes your eyeglass prescription and is inclusive of all contact lens trial lens follow up visits within 2 months or 60 days from your initial exam or when your contacts are finalized, whichever is first. Depending on the complexity of your prescription, the type of contact lens therapy, and your insurance coverage if applicable, this NON-REFUNDABLE fee can range from $129 and up.

Please check the box and sign below if you need your annual contact lens evaluation/prescription and agree to this fee:

YesNo

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