Thank you for choosing our practice for your eye care needs. Please complete the following. If you have any questions or concerns, please do not hesitate to ask for assistance. To prevent any misunderstandings, we have a stated payment policy. Payment in full is expected at the time services are provided. Payment may be made with cash, check, Mastercard, Visa, Discover, or an insurance program for which we accept assignment. If eyeglasses or contact lenses are to be ordered we require payment in full. Any balance owed must be paid in full when materials are dispensed.Patient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Nickname Sex Assigned At Birth* Male Female Gender Identity Male Female Non Binary Preferred Pronouns He/Him/His She/Her/Hers They/Them/Theirs Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneEmail* What is your contact preference? Phone Email Text DOB* MM slash DD slash YYYY Occupation* Employer* Spouse/Parent's Name (if minor) Spouse/Parent's Employer (if minor) I authorize Perimeter West Eye Care to release my medical and/or billing information to the following individuals:Name Relationship Name Relationship Name Relationship Signature - Information*Insurance InformationA copy of your card will be required.Do you have medical health insurance? Yes No Vision Discount Plan(VSP, Eyemed, Blue View Vision, Cigna Vision etc.) Vision Service Plan (VSP) None As of 11/01/2017 EyeMed changed their policies and no longer allows us to utilize routine vision benefits when billing medically (coordinate benefits). Additionally, in a few cases, it may also affect your contact lens service fees. Please contact our office, 614-789-5559, if you have any questions prior to your appointment.Medical Insurance Name of Primary Insured* Date of Birth of Primary Insured* MM slash DD slash YYYY Primary Insured's Last Four Digits of SSN* Relationship to Patient* AuthorizationMust be signed for insurance purposes.I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.Signature - Authorization*Privacy NoticeI acknowledge I have received a copy of Perimeter West Eye Care's Financial Policy and Privacy Policy.Signature - Privacy and Financial Policy*Date* MM slash DD slash YYYY Whom may we thank for referring you to our office? What brings you in today? (Please check all that apply) Glasses Contact Lenses Dr. Requested Follow-Up Eye Allergies Eye Irritation Eye Infection Headaches Flashes/Floaters Lasik Consultation Ocular Symptoms (Please check all that apply) Burning Itching Tearing Redness Eye Pain Blurred Vision Headaches Foreign Body Sensation Light Sensitivity Flashes Floaters Double Vision Headache/Migraine Discharge Loss of Vision Patient's Medical Health HistoryPatient's Ocular Health History (Please check all that apply) Dry Eyes Eye Injuries Strabismus (Eye Turns) Blindness Cataracts Glaucoma Retinal Detachment Keratoconus Color Vision Problem Amblyopia (Lazy Eye) Macular Degeneration Eye Injuries/SurgeriesEye Medications/DropsFull Name of Your Primary Care Physician Family's Medical Health HistoryHas anyone in your immediate family suffered from:Dry Eyes Yes No Relationship to patient Eye Injuries Yes No Relationship to patient Strabismus (Eye Turns) Yes No Relationship to patient Blindness Yes No Relationship to patient Cataracts Yes No Relationship to patient Glaucoma Yes No Relationship to patient Retinal Detachment Yes No Relationship to patient Keratoconus Yes No Relationship to patient Color Vision Problems Yes No Relationship to patient Amblyopia (Lazy Eye) Yes No Relationship to patient Macular Degeneration Yes No Relationship to patient Has anyone in your immediate family been diagnosed with Cancer? Yes No Type? Relationship to patient Has anyone in your immediate family been diagnosed with Diabetes? Yes No Type 1 or Type 2? Relationship to patient Has anyone in your immediate family been diagnosed with Hypertension? Yes No Relationship to patient Has anyone in your immediate family been diagnosed with Thyroid Disorder? Yes No Relationship to patient Other relevant medical history in your immediate family? Yes No Explanation of Problem Review of SystemsConstitutional (changes in weight, sleep) Yes No Explanation of Problems Ear, Nose, Throat Yes No Explanation of Problems Neurology (headaches, MS, tumors) Yes No Explanation of Problems Psychiatric (depression, anxiety, ADD, autism) Yes No Explanation of Problems Cardiovascular (heart disease, high blood pressure) Yes No Explanation of Problems Respiratory (asthma, emphysema) Yes No Explanation of Problems Gastrointestinal (ulcers, reflux, IBS) Yes No Explanation of Problems Genitourinary (genitals, kidneys, bladder) Yes No Explanation of Problems Bones/Joints/Muscles (arthritis, MD) Yes No Explanation of Problems Skin Disorders (rosacea, lupus) Yes No Explanation of Problems Blood/Lymph Yes No Explanation of Problems Allergy (seasonal, foods, medications) Yes No Explanation of Problems Cancer Yes No Explanation of Problems Currently Pregnant Yes No Explanation Currently Nursing Yes No Explanation Endocrine (diabetes, thyroid) Yes No Last Hemoglobin A1C? How frequently do you see your endocrinologist? Full name of endocrinologist? List all medications, supplements, and over the counter medicine you take on a routine basis.Are you allergic to any medications? Yes No List all medication allergies.Social HistoryDo you use tobacco products? Yes No Type/Amount/How Long? Do you drink alcohol? Yes No Type/Amount/How Long? Digital Retinal Photography ConsentAs part of your comprehensive eye exam, you can choose to have a special procedure that consists of taking a photograph of the back portion of your eye (retina). This advanced technology produces a detailed photographic image of not only the retina, but also its blood supply and the optic nerve which connects your eyes to the brain. These photos and the new technology become a permanent record of your eye health which enables the Doctor to help detect subtle changes earlier and diagnose possible disease sooner. Any change to your eye health is easier to recognize and if needed can easily be transferred to other health care providers. Diseases that can be detected with Retinal Photography includes: Diabetes Glaucoma Macular Degeneration Hypertension Retinal Abnormalities Cholesterol Stroke Cataract In most cases, retinal screening photos can replace dilation on a biennial basis. Most vision/medical insurance companies will not cover this and therefor there is a $39 fee for the procedure. If the retinal screening photo warrants further investigation, any further procedures will be billed to the medical insurance.Retinal Photos Consent* Yes, I consent to retinal photos, viewing and discussing the findings during my exam. No, I do NOT consent to retinal photos and accept that the doctor will require dilation as part of my exam. Signature - Retinal Photos Consent*Digital Prescription ConsentIn compliance with the FTC Contact Lens Rule, by signing this I am giving Perimeter West Eye Care permission to provide me with a digital copy of my prescription.Signature - Digital Prescription ConsentCAPTCHA
