Skip to content
Patient Registration Forms Logo
Foresight EyeCare Optometryadmin2017-07-06T01:14:17+00:00

Foresight Eyecare Optometry

Step 1 of 4

25%

  • Patient Registration

  • Date Format: MM slash DD slash YYYY
  • XXX-XX-XXXX

  • Employment Information

  • Vision Insurance Information

  • Date Format: MM slash DD slash YYYY

  • Medical Insurance Information

  • Date Format: MM slash DD slash YYYY

  • Assignment of Benefits: I hereby authorize direct payment of insurance benefits available for professional and/or surgical benefits to which I am entitled to Foresight EyeCare Optometry. I authorize Foresight EyeCare Optometry to release any information acquired in the course of my examination or treatment. This assignment will remain in effect until revoked by me in writing. A photocopy is to be considered as valid as original. I understand that I am financially responsible for all charges whether or not paid by insurance. HIPAA Privacy Notice: In the course of providing service to you, we create, receive, and store protected health care information that identifies you. It is often necessary to use and disclose this health care information for the purposes of treatment, payment, and health care operations involving our office. The Notice of Privacy Practices describes these uses and disclosures in detail.

  • Date Format: MM slash DD slash YYYY

  • Medical Information

  • Date Format: MM slash DD slash YYYY

  • Current Medical Problems

  • Medical History

  • All Current Medications

  • Social History

  • Ocular Surface Disease Index (OSDI)

  • Have you experienced any of the following during the LAST week?

  • Have problems with your eyes limited you in performing any of the following during the LAST week?

  • Have your eyes felt uncomfortable in any of the following situation during the LAST week?

  • Optomap Digital Eye Imaging Technology

  • AccuVision EyeCare Optometry is pleased to offer you and your family the most highly advanced technology available in eye disease detection, the Optomap Digital Retinal Imaging.

    Our Doctors are concerned about retinal diseases such as macular degeneration, glaucoma, retinal detachments, and diabetic retinopathy; all which can lead to partial loss of vision or blindness. Additionally, systemic diseases such as diabetes and high blood pressure can be detected with a retinal examination. Eye exams with retinal evaluations can help you safeguard both your eyesight and general health.

    The Optomap Digital Retinal Imaging allows us to thoroughly evaluate your internal eye health with dramatically improved precision that includes a depth in the retina not seen with regular dilation.

    The doctor strongly recommends that all patients have this procedure performed yearly. It is especially important for people who have:

      • Diabetes • High Blood Pressure • High Cholesterol • Headaches • Flashes of light • Family History of Glaucoma, Macular Degeneration, and/or Blindness • Family History of Diabetes and/or High Blood Pressure • Floating spots

    With a yearly Optomap retinal image, our doctors can track your eye health over time for comparison and treatment. Because Medical and Vision insurances do not pay for routine photos, there is a $39.00 fee for this procedure. (Please advise staff if you have a history of epilepsy.)

    You DON'T have to be dilated in most cases with an Optomap retinal photograph.

  • Date Format: MM slash DD slash YYYY
Powered by 4PatientCare
Go to Top