Please complete the information below and submit the form online

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Today's Date*

Patient Information

Name*

First Last Suffix

Gender Identified With*

Female
Male

Gender Pronouns

Date of Birth*

Appointment With*

Dr. Sutton
Dr. Faiq
Dr. Bae
No Doctor Preference

Reason for Visit*

Comprehensive Eye Exam
Contact Lens Exam
Medical Exam

Contact Information

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Phone Number to Text

Email Address

Please provide us your email address.

Address*

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

Communication Preference

How were you referred to our office?

If other, please explain

Vision Insurance

Please bring all insurance cards with you to your appointment.

Select your vision plan*

VSP
EyeMed
No Vision Plan

Policy Holder's SSN

Primary Medical Insurance

Select your primary medical plan*

Insured's Name

First Last

Insured's Date of Birth

Do you have Secondary Medical Insurance?*

Yes
No

Secondary Medical Insurance

Select your secondary medical plan, if applicable

Insured's Name

First Last

Insured's Date of Birth

Eye History

Do you have difficulty with any of the following?

Select all that apply.

Are you experiencing any of the following?

Select all that apply.

If you are experiencing other, please explain.

Have you had any eye trauma and/or eye surgery?

Yes
No

Have you had Lasik?

Yes
No

When/where did you have your Lasik operation?

What is your current eyewear?

Select all that apply.

Are you interested in trying contact lenses?

Yes
No
Maybe

Are you interested in Lasik?

Yes
No
Maybe

Family History

Has anyone in your family been diagnosed with:

Select all that apply.

Medical History

Please provide your primary care physician's information along with any additional doctors you are currently seeing to help us better coordinate your care.

Press the plus sign to add another row.

Dr Name	Specialty	Office Name	Office Number

Do you have any medical problems?*

Yes
No

Please select the medical condition*

Please tell us about your medical condition*

If diabetic, please provide your latest A1C level.*

Do you take any medications?*

Yes
No

Please select the medications you are taking*

Please tell us about the medication you are taking*

Please list any allergies, including drug allergies.

Click the plus sign to add an item.

Do you use/have you used tobacco products?

Yes
No
Quit

If you quit smoking, how long ago?

Checking the Health of Your Eyes

Recommended annually for ages 5 and up. Please select an option.

Optomap Retinal Imaging

NO Drops required
NO light sensitivity/No Blurry Vision
The photo takes less than 2 minutes to take
Permanent digital image of the retina
NOT covered by Insurance

The cost for this service is $39.00. If you and a family member decide to have this service done on the same day, the additional OptoMap will be $20.00 for any other family member(s). (Must be same day No Exceptions.)

Dilation Drops

Blurred near vision for 2-4 hours or more
Light sensitivity for 2-4 hours or more
Longer overall time for exam while drops take effect
No permanent record of retina
Covered by Insurance*

Dilation is recommended if you have/had the following:

Floater/Flashes of light
Diabetes/Pre-Diabetes
Cataracts

Optomap vs Dilation*

Please read through the importance of Optomap retinal imaging and Dilation drops which can be found here: Optomap vs Dilation

I have read the Optomap vs Dilation document

Retinal Exam Options*

Optomap retinal imaging at $45
Dilation drops
Discuss with the Doctor

Routine vs. Medical Exam*

Please read through the difference between a routine vs a medical exam which can be found here: Routine vs. Medical Exam

I have read the Routine vs Medical document

Policies

Read the Financial Agreement here: Financial Agreement Information

Financial Assignment Information*

I understand and agree to the Financial Assignment Information Policy.
No, I do not agree with the Financial Assignment Information Policy.

I understand and agree that health/vision insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Signature

Health Information Protection*

Yes, I have read or had explained to me by this office the NPP & I wish to continue my care under said terms.
No, I do not wish to continue my care under said terms.

Privacy Policy

Signature

Contact Lens Fees*

Yes, I have read or had explained to me by this office the contact lens exam fees & I wish to continue.
No, I do not wish to have a contact lens exam.

Contact Lens Exam Fees Policy

Contact Lens Return and Exchange Policy

I have read or had explained to me by this office the contact lens return and exchange polilcy & I wish to continue.

Contact Lens Return and Exchange Policy

Signature

Contact Lens Prescriptions

FTC requires that the contact lens patient elect the method of contact lens prescription receipt upon completion of the contact lens evaluation and fitting. I elect to receive my contact lens prescription via: (please select one)

The practice will store a digital copy of my contact lens prescription. I have access to my prescription as needed.
Printed and picked up from the practice.

CL Rx Consent

I have read and understand the above information. I have made my election of how I will receive a copy of my contact lenses prescription once fitting is complete. I acknowledge that it is my responsibility to ask questions if I do not understand the risks involved, and see the doctor immediately if there is a problem with my eyes during or after my contact lens use.

I understand and consent
I do not consent

Signature

Consent for Electronic Delivery of Prescription (Eyeglasses and Contact Lens)

I consent to receiving my eyeglass and/or contact lens prescription electronically via email or text:

Yes
No
Other: The practice will securely store a digital copy of my eyeglass and contact lens prescriptions, providing me with access whenever needed.

Do you wish to receive your eyeglass and/or contact lens prescription via:

Text
Email

Phone Number

Email Address

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Comments

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