Exam Paperwork Step 1 of 9 11% Please note: all fields are required to be completed before the form will submit.Title* Mr Ms Mrs Dr Name First Last Sex* Male Female Birthdate* MM slash DD slash YYYY Age*Social Security Number*(We need this to look up insurance)Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email address* Cell phone number*Emergency number*Emergency contact* Relationship* Marital Status* Single Married Other Employment* Employed Retired Unemployed Student Employer Work PhoneYour Occupation Primary Care Physician* Physician Phone Number*Last Eye Doctor* How did you hear about our practice? Walk-In Insurance LensCrafters Website Alafaya Vision Center Website Google Yelp Patient Referral Name of person who referred you First Last Insurance InformationDo you have insurance?* None/Self Pay Yes Vision Insurance Vision Insurance ID # Group # Medical Insurance Medical Insurance ID # Group # Person Responsible For Bill(if different from patient)Guarantor Name First Last Social Security NumberBirthdate MM slash DD slash YYYY Relationship Spouse Child Domestic partner PhoneEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code RECEIPT OF NOTICE OF PRIVACY PRACTICESI have reviewed and accept the terms of the Alafaya Vision Center Notice of Privacy Practices* I have read and agree to the Privacy Policy Signature*Date* MM slash DD slash YYYY CONTACT LENSESHave you ever worn contact lenses? Yes No When was the last time you used contacts What type of Contacts do you wear? (Please check ALL responses that apply) Hard Lenses Astigmatism/Regular Multifocal/Bifocal Monovision (one eye near, one eye far) OR Soft Lenses Astigmatism/Regular Multifocal/Bifocal Monovision (one eye near, one eye far) CONTACT LENS CARE AND INSTRUCTIONSPlease review and follow: Name First Last Birthdate MM slash DD slash YYYY Cell phone numberYOUR DOCTOR WILL DISCUSS WITH YOU WEARING & REPLACEMENT SECHDULE FOR YOUR CONTACTS. REMOVE LENSES PROMPTLY AND DISCONTINUE WEAR IF YOU ARE EXPERIENCING ANY OF THE OCULAR SYMPTOMS BELOW:Discomfort or pain Blurred, cloudy or foggy vision Redness of the eye You suspect something is wrong Eyes feel irritated Foreign body sensation Call the prescribing doctor for a consult if any of the above signs and/or symptoms are noted. If you believe you are having a true ocular emergency after hours please visit your local ER. Important points about contact lenses: Absolutely NO sleeping in contact lenses unless indicated Wash hands thoroughly before handling contact lenses Insert contacts prior to application of makeup, lotions, creams etc…**NOT FOLLOWING PROPER CONTACT LENSES CARE, REPLACEMENT, USE AND HYGIENE PROTCOLS CAN RESULT IN POTENTIALLY BLINDING MICROBIAL INFECTIONS OF THE EYE** PRESCRIPTION EYEGLASSES: As a contact lens wearer you should maintain a pair of prescription glasses. Contact lenses are not to be your only means of vision correction. NON-PRESCRIPTION SUNGLASSES: Quality sunglasses with adequate UV protection are essential for all patients in order to protect your eyes from the sun. PATIENT STATEMENT: I have read the information provided above. I understand that compliance and follow-up care is extremely important with contact lens use and that it is my responsibility to schedule and keep my follow-up appointments. If I fail to do so, I will not hold this office responsible for any eye health related problems. Signature OFFICE FINANCIAL POLICY We are pleased you have selected us as your eye care provider. For your knowledge, our financial policy is outlined below. Promise to pay: Amounts for services provided to you or your family members that are minors may be charged to your Account, unless you specifically instruct us otherwise. You promise to pay us all amounts owed on your Account under the terms of this Financial Policy when billed. If you have insurance, the amount you owe for the services may be estimated based on the amount anticipated to be paid by your insurance company. Insurance claims, benefit, and coverage information are agreed upon between the patient and insurance company and are ultimately the patient’s responsibility. In the event that you insurance company is slow to pay or disallows a claim payment, the account balance is your full responsibility. REFUND POLICY: Services: Our staff and our doctors take the upmost care with each patient to provide the best possible services Eye exam and professional fees are not refundable. Contact lenses: There are no refunds on contact lens purchases. Unopened, unmarked boxes of contacts may be exchanged within 30 days of purchase. Additional charges may be applied to your account for the below reasons: Late payment fee: If we do not receive payment in full of your balance within 30 days of the statement date shown on your statement, you will be a assessed a late payment fee of $25.00 and then 2% of your unpaid balance each month that the balance is not paid in full. We may not allow further appointments, unless in exceptional circumstances, until we receive full payment of your balance. Returned payment fee: If any check or other payment that you have made on your Account is returned unpaid, you will be charged a return payment fee, which is $25.00. Contact lens wearers: You have 30 days from the initial fit of your contacts lenses to have (3) progressive follow up visits at no charge; certain restrictions may apply especially with rigid gas permeable lenses and if during the contact lens fitting period you develop any corneal/contact lens complications, infection of the eye, or any other ocular condition . I understand that I will be charged for any adjustments after the free follow-up period and the replacement of any lost or damaged lenses. NO EXCEPTIONS ARE MADE TO THE REFUND/FINANCIAL POLICY ABOVE. Communications. By signing this policy you are consenting to allowing our office to communicate with you via phone, text, email, & mail. This communication can include but is not limited to your patient records, receipts and promotional matters.Signature*Date* MM slash DD slash YYYY INFORMED CONSENT OR REFUSAL FOR A DILATED FUNDUS EXAM A dilated exam is a complete exam that helps the doctor detect cataracts, glaucoma, retinal disease, detachments, malignancies and much more, all of which can lead to permanent vision loss. Side effects of dilation typical lasts 4-6 hours, including blurry vision close up and distance. Other side effects include light sensitivity and mild burning upon instillation of drops. In RARE cases induced ocular hypertension with redness, sharp pain, blurry vision and nausea can occur. If this happens seek immediate medical attention. .PLEASE SELECT AN OPTION AND SIGN BELOW* Yes, I have read the above and consent to the dilation procedure. I refuse the dilation procedure and understand the risks associated with not dilating my eyes today. Sign*Date* MM slash DD slash YYYY Medical HistoryAre you Pregnant or Nursing?* Yes No Last eye exam* Are you Diabetic?* Yes No Last fasting blood sugar Date MM slash DD slash YYYY HbA1c Date MM slash DD slash YYYY Last visit w/PCP/MD Average fasting blood sugar Do you have medication allergies?* Yes No List ANY medication allergies:* Are you currently taking any medications?* Yes No List Current Medications:*List major injuries/surgeries/hospitalzations (if none, please type "none"):* Any eye surgeries?* Yes No List here Do you wear glasses* Yes No Do you wear contacts?* Yes No Contacts lens brand Do you use tobacco products?* Yes No type/amount/how long Do you drink alcohol?* Yes No type/amount/how long Have you been exposed or infected with: Gonorrhea Hepatitis HIV Syphilis No Family HistoryOcular/Systemic ConditionsFamily Member Affected (Maternal/Paternal) Blindness due to Disease Family Member Affected Blindness due to Injury Family Member Affected Glaucoma Family Member Affected Macular Degeneration Family Member Affected Retinal Detachment Family Member Affected Retinal Degeneration Family Member Affected Arthritis Family Member Affected Cancer Family Member Affected Type: Diabetes Family Member Affected Heart Disease Family Member Affected Hypertension Family Member Affected Kidney Disorder Family Member Affected Thyroid Disease Family Member Affected OTHER Family Member Affected NONE OF THE ABOVE Patient History/Review of SystemsCardiovascular Heart Disease Elevated Cholesterol High Blood Pressure Hematologic Anemia Coagulation Disorder Leukemia Musculoskeletal Arthritis Muscle Pain Joint Pain Rheumatoid arthritis Integumentary (Skin) Lupus Psoriasis Eczema Gastrointestinal Diarrhea Constipation Respiratory Asthma Bronchitis Emphysema Endocrine Diabetes Thyroid Dysfunction Psychiatric ADD/ADHD Anxiety Depression Constitutional Fever Weight Gain Weight Loss Genitourinary Kidney Problems Bladder Problems Ears/Nose/ Throat Chronic Cough Dry Mouth General Allergies Head Colds Eyes Crossed Eyes Lazy Eye Glaucoma Retinal Disease Retinal Detachment Cataract Other Neurologic Headaches Migraines Seizures Multiple Sclerosis NONE OF THE ABOVE OCULAR HISTORY-CHECK YES OR NOYESNOBlurry VisionDouble VisionEye FatigueLoss of side visionDrynessRednessItchingBurningMucous DischargeEye PainLight SensitivityWatery EyesFloatersFlashesDistorted Vision/HalosOther Please note any other medical or ocular conditions not listed Name First Last Birthdate MM slash DD slash YYYY Cell phone numberDate MM slash DD slash YYYY SignatureSection Break
