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Eclectic Eyewear Registration Form
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2017-07-28T19:06:28+00:00
Eclectic Eyewear Registration Form
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Name
First
Last
Date
MM slash DD slash YYYY
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
Age
Email
Phone Numbers: Mobile
Phone Numbers: Work
Phone Numbers: Home
Parent's Name (if under 18)
Spouse's Name (if married)
Occupation or Grade (if student)
Employer
How did you hear about us?
School (if student)
Approximate date of last exam
Previous Eye Doctor
Are you presently wearing glasses?
If not, have you ever worn glasses?
Are you currently wearing contacts?
Do you sleep in contacts?
If so, how long?
Type of contacts worn?
Soft Lenses
Hard or Gas Permeable
Daily Wear
Extended Wear
Disposable
Frequent Replacement
What are your reasons for visiting our office today? (Check all appropriate items)
General check-up
Lost or broken glasses
Want new glasses
Blurred distance vision - without glasses
Blurred distance vision - with current glasses
Blurred near vision - without glasses
Blurred near vision - with current glasses
See spots or floaters
See flashing lights
Temporary vision loss
Eyes water
Eyes burn
Eyes red
Eyes feel dry
Eyes itch
feel mattering
Headaches
Eyestrain
Pain in eyes
Double vision
Light sensitive
Glare
Problems with current contact lenses
Want a new type of contacts - Soft Contacts
Want a new type of contacts - Daily Wear
Want a new type of contacts - Disposable
Want a new type of contacts - Hard or Gas Perm Contacts
Want a new type of contacts - Extended Wear
Want a new type of contacts - Frequent Replacement
Want an updated prescription for the exact same type of contacts currently being worn.
Other (please list) :
Your general and ocular health (past or present). Check all that apply.
High blood pressure
Heart problems
Respiratory problems
Multiple sclerosis
Thyroid condition
Diabetes
Allergies
Asthma
Migraine headaches
Arthritis
Blindness
Glaucoma
Lazy eye
Retinal disorder
Cancer
Cataracts
Eye turn
Poor color vision
Currently pregnant
HIV positive
List any other visual and/or health conditions not listed above
List any eye injuries, diseases, or surgeries you have had
Has any family member had any of the above conditions? Please list relative and condition.
List medications you are currently taking
Do you have any allergies to medications?
List any insurance or health care plan you have which will pay toward your eyecare
Method of payment:
Cash
Check
MC/Visa
American Express
Discover
Other
Signature
We are committed to providing quality eyecare to our patients by using the most advanced equipment and techniques. The following tests can often identify changes at early stages before they become significant problems. We strongly recommend that our patients receive the following tests as part of their comprehensive eye examination.
DILATION OF THE EYES
In order to more thoroughly examine the inside of the eye for diseases such as glaucoma, cataracts, tumors, and retinal degenerations it is best to dilate (enlarge) your pupils. After the initial examination, 2-3 drops will be instilled in each eye. It then takes an additional 20-30 minutes for your pupils to dilate. Your pupils will gradually return to their normal size over a period of 4-6 hours. During that time you will be sensitive to bright lights and reading and other close work, including computer work, will be difficult. We will provide free, disposable sun shields if needed for light sensitivity. Most people are comfortable driving, however, if you do not feel comfortable with your vision after dilation, please call someone to pick you up or bring someone to drive you home. If dilation should be contraindicated in your case, the doctor will inform you. We realize that not every patient’s schedule will allow him or her to undergo this procedure. However, we feel that the benefits outweigh the disadvantages and recommend that our patients have their eyes dilated when possible. You may return to have your eyes dilated at a later date if you choose. There will be no additional charge as long as you do so within 30 days of today’s examination date. There may be some instances in which we may not be able to dilate your eyes the same day as your examination due to scheduling, an emergency, or other unforeseen circumstances.
Do you want your eyes dilated today?
Yes
No
VISUAL FIELD SCREENING
Most major causes of blindness in the United States can often be detected by changes in the visual field. A highly sophisticated computerized instrument now enables us to provide a visual field screening in less time and at much less cost. This instrument checks for areas of reduced vision in the central (straight-ahead) and peripheral (side vision) areas. Visual field testing is important in the early diagnosis of glaucoma, retinal problems, and some neurological diseases such as brain tumors and optic nerve disease. Unfortunately, an individual does not notice most visual field defects until very late stages. Early detection significantly increases the chances of either curing the disorder or at least minimizing its effects. There is an additional fee of $10.00 for the visual field screening.
Do you want to have the visual field screening performed?
Yes
No
If you chose not to have one or both of the above tests performed, please sign the liability release below:
Liability Release: I have been informed by the office of Kevin Gajda, O.D. and his associate optometrists of the importance of pupil dilation and visual field screening. I have chosen not to have one or both of these tests performed, and I will not hold the office of Kevin Gajda, O.D., his associates, and/or his staff responsible for any disease or pathology (or its effects) that goes undetected due to the lack of diagnostic information that could have been obtained by these testing procedures.
Name (Please print):
Signature
Date
MM slash DD slash YYYY
CONSENT
I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews. I have been informed that I may review the practice’s Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restrictions, they must follow the restriction(s). I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.
Signature (Patient, parent or legal guardian)
Date
MM slash DD slash YYYY
If signed by patient representative, state relationship to patient
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