Patient Information

For any questions that are not applicable to you, please type NA.

Patient Information

Last: *

First: *

MI *

Street: *

City: *

State: *

Zip Code: *

Home Phone: *

Work Phone:

May we contact you by text? If yes, what number? *

No

Yes Yes

Patient's SSN:

Employer or School *

Occupation (or Grade)

Birthdate: MM/DD/YYYY *

Gender *

Email Address: *

Spouse (or Parent's Name):

Spouse (or Parent's Work)

What is the major purpose of this visit? *

Any problems with your current contact lenses or glasses?

VERY IMPORTANT! NEW PATIENTS ONLY:

Who may we thank for referring you to our office?

If not referred, how did you choose our office?

Insurance Information

Please note that most insurance does NOT cover the Contact Lens Evaluation/Follow-up.

Vision Insurance:

Subscriber Name:

Subscriber SSN:

Subscriber Birth Date:

Primary Medical Insurance:

Subscriber Name:

Subscriber/Member ID: *

Lifestyle Questions

Have you been diagnosed or treated for any of the following?

Patient Medical History

The information in this confidential case history form is critical to the evaluation of your vision and health.

Name of Family Physician: *

Location

Date of Last Physical Check-up:

CURRENT MEDICATIONS
(Rx or Over-the-Counter)

(List name of medications including eye drops, vitamins & birth control pills *

Allergies to medications? *

Yes

No

If so, what medications?

Do you use cigarettes/tobacco? *

Yes

No

Do you drink alcohol? *

Yes

No

Have you had any surgeries? *

Yes

No

If so, please list *

Have you ever been diagnosed or treated for the following health problems?

*

	Yes	No
Allergy	Yes	No
Cardiovascular	Yes	No
Endocrine	Yes	No
Gastrointestinal	Yes	No
Ears, Nose, Throat, Mouth	Yes	No
Hematologic/Lymphatic	Yes	No

	Yes	No
Immunologic	Yes	No
Integumentary/Skin	Yes	No
Muscoskeletal	Yes	No
Neurological	Yes	No
Psychiatric	Yes	No
Respiratory	Yes	No

If you answered yes to any of these, please describe. *

Patient Eye History

Date of Last Eye Exam *

By Whom? *

Are you interested in contact lenses? *

Yes

No

Do you currently wear contacts? *

Yes

No

What kind?

Solutions used?

Are you satisfied with the vision and
comfort of your contact lenses?

Yes

No

Family Medical/Eye History (Check all that apply)

Is there a family medical history of any of the following? *

	Mother's Side	Father's Side	None in Family
Blindness	Mother's Side	Father's Side	None in Family
Cataracts	Mother's Side	Father's Side	None in Family
Corneal Problems	Mother's Side	Father's Side	None in Family
Diabetes	Mother's Side	Father's Side	None in Family
Glaucoma	Mother's Side	Father's Side	None in Family
Heart Disease	Mother's Side	Father's Side	None in Family
Lazy Eye	Mother's Side	Father's Side	None in Family
Macular Degeneration	Mother's Side	Father's Side	None in Family
Retinal Problems	Mother's Side	Father's Side	None in Family

Notices

Persons with whom you may discuss my medical/financial information. *

Computer Vision Testing

Computer Vision Syndrome is caused by the constant effort it takes for your eyes to focus on a computer screen. Unlike an easy-to-read book, the images on a computer screen are made up of tiny, glowing dots called pixels. Without clearly defined edges or background contrast, your eyes can lock the images into focus. They continually drift out of their natural focal resting point and then strain to regain focus on the screen. This constant refocusing can occur in thousands of times an hour — overworking your eye muscles and causing painful eyestrain symptoms including tired and sore eyes, headaches, blurred vision, and general fatigue. If you work at a computer more than 2 consecutive hours in a day, we strongly recommend evaluating your eyes with the PRIO computer test during your visit today. With the results of this test, Dr. Fry will be able to prescribe the most accurate prescription designed specifically for your computer vision needs.

I want the PRIO computer test: *

Yes

No

Initials *

Financial Info

I. Third Party Benefit Plans:

When making a third party claim, I authorize the release of my medical information to process my third party claim. I authorize the release of any information pertinent to my case to any third party, adjuster, or attorney involved in resolving the financial status of my account. I authorize my third party plan to pay Premier Eyecare directly.

II. Consent for Treatment

By signing this form, I Consent to treatment for myself and/or on behalf of the Minor for which this Medical History information pertains. I give permission for the doctor(s) to examine, diagnose and initiate treatment as deemed appropriate. I further, attest that I am the Parent or Legal Guardian of the Minor and have the authority to authorize care and treatment.

Patient Initials: *

THE FINANCIAL POLICY OF PREMIER EYECARE

All fees are due the day services are rendered or materials are ordered.
We accept the following forms of payment: Cash, American Express, Visa, MasterCard, and Discover. We also participate in Care Credit and Tradebank.
The patient who seeks care is responsible for the payment of all fees.
The person who brings a child into the office is responsible for all fees.
When we are not a provider for a third party, the patient who seeks care is responsible for the payment of all fees. We will provide a fee slip to submit to your third party for reimbursement directly to you.
When we are a provider for a third party, any deductibles, co-payments or patient responsibility fees are due when services are rendered or materials are ordered.

NO SHOW AND LATE POLICY

Our goal is to provide quality medical care in a timely manner. In order to do so we have implemented a no show appointment/late cancellation policy. This policy enables us to better utilize available appointments for our patients.

We understand that time is valued to all of us. We also understand that some things are out of our control. To be efficient in our office we ask that you arrive 15 minutes prior to your appointment to allow yourself time to check in.

If for some reason you are more than 10 minutes late to your scheduled appointment time we will do our best to accommodate you and work you into our schedule as time allows. We may ask you to reschedule to the next convenient time for you.

By signing below I have read and understand that any no shows, late cancellations/reschedules made less than 24 hours prior to the scheduled appointment will result in a $40.00 fee. This fee is not covered by insurance.

Name of Patient/Parent or Guardian *

Today's Date *

Please Read and Sign if Interested in Contact Lenses

Please Read and Sign if Interested in Contact Lenses

Professional Standards of Care require that all people who wear contact lenses have a full comprehensive exam and contact lens evaluation at least once every year. This form is intended to make clear any misconceptions concerning the professional services and material costs of contact lenses. Your vision benefits may not cover, or may only cover a portion of, the charges for a contact lens evaluation. Please read carefully and sign at the bottom:

We will not dispense contact lenses or write a contact lens prescription without a comprehensive eye exam and contact lens evaluation, including all necessary follow-up visits, each and every year.
A comprehensive eye exam consists of tests which include:

Determination of the refractive status of your eyes (myopia, hyperopia, astigmatism, presbyopia.)
Evaluation of ocular tissues, internally and externally, and any diagnosis of diseases or disorders relating to the eye.
Assessment of the functional ability of the visual system.

A CONTACT LENS EVALUATION must be done IN ADDITION to the comprehensive eye exam, regardless of whether or not you have a change in your contact lens prescription.

These tests are for contact lens wearers only and include:

Measurement of the curvature of the cornea to determine the proper parameters of a contact lens which will best fit each eye, and for previous wearers, to assure that your current contact lenses are still the proper fit. Corneal topography screening is included.
Evaluation of the performance of the current and/or new contact lenses on each eye (visual acuity, coverage, centration, movement, tear exchange, cleanliness, etc…)
Assessment of the ocular tissues involved in contact lens wear and determination if these tissues are responding favorably to contact lens wear.
Choosing the correct lens materials and designs for your individual needs utilizing the latest technology available.
Ongoing follow-up visits as needed are included in the professional fee for up to 90 days. It is the patient's responsibility to communicate with our office if any changes are desired within the fitting time frame. Additional visits outside of the initial 90 days will be charged $55 per visit.

There is an ADDITIONAL PROFESSIONAL FEE associated with the Contact Lens Evaluation. This fee is dependent on the level of complexity of the fitting process and does not include the price of the contact lenses.

Level 1 $ 89 Soft spherical CL and Level 2 re-fit with no follow-up

Level 2 $159 Soft toric CL requiring follow-up visit(s) or Level 3 re-fit with no follow-up

Level 3 $199 Multi-focal soft CL, high astigmatism soft toric CL,
SV hybrid, SV RGP or CRT re-fit

Level 4 $299 Multi-focal hybrid or RGP, multi-focal soft toricL contact lenses, or post-RK re-fit

Level 5 $399 CRT re-fit

Level 6 $899 Corneal Refractive Therapy (CRT) initial fitting (over 18 years), keratoconus hybrid or RGP, or high myopia (>10 D) medically necessary, or post-RK initial fitting

Level 7 $1750 Scleral Lens Fitting

VISION BENEFITS

If you have vision benefits, your exam co-pay is only for the comprehensive portion of the exam. Contact lenses are considered an elective form of vision correction; therefore, the contact lens evaluation is NOT covered by the comprehensive exam coverage under your vision benefits. Unless your vision carrier provides some reimbursement toward your contact lens evaluation and/or contact lenses, you are responsible for the full amount of the contact lens evaluation fee on the date of service.

I have read and by signing, I understand that if I choose to be fit with contact lenses, I am financially responsible for all fees not covered by my vision benefits.

Name *

Date *

Retinal Imaging

Dilation of the pupils:

Dilating the pupils is still considered the "standard-of-care" for examining the tissues of the eyes. Eye drops are used to temporarily relax the iris muscles in order to prevent the pupils from constricting when light is presented to the eyes. This recommended for everyone having a comprehensive eye exam.

HD Retinal Photography:

Our wide-angle retinal camera (Optos Daytona) allows for high-definition images of the back of your eyes. This assists the doctor in examining the eyes and utilizes technology to see structures in the eyes which may be missed without dilation. This is also an excellent way to document the images in your record for future reference if needed.

OCT (Optical Coherence Tomography)

OCT provides a view of the retinal layers in the macular area. Without it, only observation of the top layer of the retina is possible. Think of a layered cake. If you only see the top layer of icing, you will miss all of what is inside the cake. Many pathologies occur beneath the surface of the retinas; therefore, it is important to examine this area thoroughly.

Premier Eyecare highly recommends a combination of these tests in order to receive the most thorough evaluation of your retinal health.

Please read and sign at the bottom showing that you have an understanding of the following:

* I understand that a complete retinal health evaluation is not covered by health insurances and has an additional fee of $69.00.

* I understand that dilation is included with my exam and will not have an additional fee.

* I understand that by refusing dilation and retinal imaging I am going against the doctor's recommendations and will not hold the doctor responsible for any pathology that is missed due to a lack of diagnostic information that could have been obtained by using the aforementioned options

Please notify the technicians which option you would prefer for your eye health examination.

Consent For Use Or Disclosures Of Health Information

Name of Patient/Parent or Guardian *

Today's Date *

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Blurry Vision	Cataracts	Crossed eye/Eye turn
Eye Infections	Flash of light	Glaucoma
Headaches	Itchiness	Macular Degeneration
Retinal Detachment	Tearing	Uncomfortable glasses
Burning	Corneal Abrasions	Double Vision
Eye Injury	Floaters/Spots	Grittiness
Iritis/Uveitis	Lazy Eye	Occasional dryness
Sunlight Sensitivity	Trouble seeing at night	Other Eye Disorders Other Eye Disorders