TSO Keller

WELCOME TO OUR OFFICE
Today's Date*
Date Format: MM slash DD slash YYYY
Patient Information
Name*
First MI Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Patient's SSN
Date of Birth*
Date Format: MM slash DD slash YYYY
Age
Sex
- M
- F
Weight
Height
Race
Employer (or School)
Occupation (or Grade)
Spouse (or Parent’s Name)
Spouse (or Parent’s Work)
Email Address
Is it ok to contact you via Email/Text for appointments and when your glasses/contact lenses are ready:
- Yes
- No
Any problems with your current contact lenses or glasses?
VERY IMPORTANT! NEW PATIENTS ONLY:
Who may we thank for referring you to our office? Name of friend or relative
If not referred, how did you choose our office?
- Insurance List
- Saw Sign/Building/Billboard
- Newspaper/Radio/TV
- Other
If Other: Please explain
Lifestyle Questions
Do you…(check box if your answer is yes)
- ..work at a computer?
- ..think you might benefit from thinner, lighter lenses?
- ..have interest in a “test drive” of the latest contact lens designs
- ..spend time outdoors?
- ..have prescription sunwear?
- ..prefer not to wear your glasses at times?
- ..want information on Laser Vision Correction surgery?
- ..have more than 1 pair of current Rx eyewear?
- ..have children?
- ..have family members in need of eye care?
How many hours per week do you spend outdoors?
Your Eye Health Information
Date of Last Eye Exam
Date Format: MM slash DD slash YYYY
By Whom?
Have you experienced, been diagnosed or treated for any eye problems? Please describe.
Contact Lens History
Have you ever tried contact lenses?
- Yes
- No
Do you currently wear contact lenses?
- Yes
- No
What kind?
Solutions used
Are you satisfied with the vision and comfort of your contact lenses?
- Yes
- No
Are you interested in contact lenses today?
- Yes
- No
Do you sleep in your contact lenses?
- Yes
- No
How often do you throw your contact lenses away?
Patient Medical History
Name of Family Physician
Date of Last Physical Check-up
Date Format: MM slash DD slash YYYY
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?
Have you had any surgeries?
- Yes
- No
Please list surgeries:
Do you currently use cigarettes/tobacco?
- Yes
- No
Allergies to medications?
- Yes
- No
If not, have you ever used cigarettes/tobacco?
Are you being treated for the following health problems?
Allergic/Immunologic - drug, environmental, rheumatoid, lupus, AIDS
- Yes
- No
Cardiovascular - heart disease, high blood pressure, stroke, high cholesterol
- Yes
- No
Constitutional - weight loss/gain, fever, fatigue, trauma
- Yes
- No
Endocrine - ex: type 1 diabetes, type 2 diabetes, thyroid dysfunction
- Yes
- No
Gastrointestinal - Crohn’s, colitis, ulcer, digestive
- Yes
- No
Genitourinary - STD, viral herpes, Chlamydia
- Yes
- No
Head/Ear - headaches, encephalitis, tinnitus, vertigo
- Yes
- No
Blood disorders - anemia, leukemia, large blood volume loss
- Yes
- No
Skin disorders - rashes, eczema, psoriasis
- Yes
- No
Musculoskeletal - fibromyalgia, muscular dystrophy, osteoarthritis
- Yes
- No
Neurological - epilepsy, multiple sclerosis, Parkinsons, Alzheimer’s
- Yes
- No
Psychiatric - depression, panic disorder, bipolar, schizophrenia
- Yes
- No
Respiratory - bronchitis, asthma, emphysema
- Yes
- No
Is there a family medical history of any of the following:
Blindness
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Corneal Problems
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Diabetes
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Glaucoma
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Heart Disease
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Relationship: (Whom; Mother's or Father's side?)
Macular Degeneration
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Retinal Problems
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Authorized Access/Policies/Insurance/HIPPA
Please list anyone authorized to have access to your medical records including but not limited to: prescriptions, exam records, insurance explanation of benefits, appointment history and statements.
Signature*
By signing this form, I consent to treatment for myself or on behalf of the Minor for which this information pertains. I give permission for the doctor/s to examine, diagnose and initiate treatment as deemed appropriate. I further attest that if I am signing on behalf of Minor that I am the Parent or Legal Guardian of the Minor and have the authority to authorize care and treatment.
Signature*
Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company and not TSO of Keller. On occasion the doctor may consider your visit to be medical in nature and not routine which will require us to bill your medical insurance for the visit or bill you directly if no medical insurance is available. If your insurance company has not reimbursed our office in full within 90 days, we will send you a statement and your insurance company will then pay you directly. Additionally any refunds for purchases/payments made at this office using a credit card will incur a 4% charge. By signing below, you give us authorization to electronically bill your insurance company for your visit, and also give acknowledgment of receipt of Bhavesh Patel, OD PLLC Notice of Privacy Practices (HIPPA).
CONTACT LENS FITTING & FOLLOW-UP POLICY
Patient Signature*
Failure to show up or contact the office within one month of the original contact lens fitting, results in loss of any fees applied towards this procedure. If additional follow-ups are needed after the contact lens prescription has been determined there will a $24 charge for each additional office visit pertaining to your contact lenses.
Do's:
1. Follow all of your doctor’s instructions and call the office if have any questions.
2. Return to the office for your regularly scheduled follow-up visits. It is the patient's responsibility to schedule and keep appointments.
3. Follow your wearing time schedule as prescribed by your doctor.
4. Always thoroughly wash, rinse, and dry hands before handling lenses.
5. Clean your lenses after wearing and before storage.
6. Be thorough, but careful while cleaning a lens, they can tear or crack.
7. Use fresh solution when storing in case.
8. Rinse the storage case wells out with warm tap water then with saline after each use and let air dry with covers off.
9. Sit or stand close to a sink while inserting lens to avoid loss of lenses.
10. Re-clean lenses that have dropped on the floor or on your clothes.
11. Always close drain when working near sink. A dark face cloth or towel may also be used to cover the drain.
12. Wear eye protection now that you wear contacts for Racket sports, hockey, etc. Wear safety eyewear to avoid trauma.
13. Avoid contact with sprays and aerosols. (Hairspray, spray paint etc.)
14. Apply hairspray, deodorant or spray cologne before lens insertion or keep your eyes tightly closed until the spray has settled. Hair spray is very uncomfortable and hard to clean.
15. Avoid harmful vapors and fumes especially in work areas while wearing lenses. Inform your employer that you wear contact lenses so they can recommend proper eyewear.
16. Avoid dusty environments: wear protective eyewear.
17. Use caution when adjusting to temperature extremes such as ovens, fireplaces, freezers or sub-zero weather.
18. While inserting the lenses, some patients find it easier to hold back the upper eyelid back.
19. Keep a storage case and a small bottle of lubricant or saline with you at all times for emergency use.
20. Apply all cosmetics after inserting contact lenses, including lotions and foundations as well as all eye make-up
Don'ts:
1. Don't wear lenses if they are suddenly/ consistently uncomfortable.
2. Don't wear your lens if you notice a chip or tear.
3. Don't exceed your wearing schedule during the adjustment period.
4. Don't wear your lenses for maximum hours if you have not worn them for a day.
5. Don't handle your lenses roughly and avoid contact with fingernails.
6. Don't insert your lenses over an open drain.
7. Don't move around if a lens is dropped. Check your lashes, clothes, shoes and immediate area.
8. Don't pick up a dropped lens with your fingernail to lift it. Dampen your finger for the lens to stick.
9. Don't switch to a "thermal" (heat) cleaning system after using a "chemical" cleaning system or vice versa. Doing so can damage your soft lenses.
10. Don't use any other solutions than those your doctor prescribed.
11. Don't switch or mix brands of solutions without doctor's approval.
12. Don't start using different brands of solution simultaneously. Start them separately so if there is a problem you can identify it.
13. Don't touch solution bottles to lenses or case. It can contaminate a sterile bottle of solution.
14. Don't try to wear a soft lens that was left out of solution and has become brittle.
15. Don't wet lenses by putting them in your mouth or using tap water.
16. Don't overfill the storage case; it can cause a chip or cut lens when closing lenses.
17. Don't use eye drops like Murine or Visine while wearing lenses.
18. Don't force apart a soft lens that is folded over itself. Put the lens in your palm and soak with saline and work it out gently.
19. Don’t rub the lenses with towels, tissue or shirttails, it may scratch.
20. Don't swim or shower with lenses on because you are risking getting an infection.
21. Don't wear lenses if you have a cold or flu.
22. Don't leave lenses in "hot spots" (TV, glove box, hot sand etc).
23. Don't sleep in lenses without doctor's approval.
24. Don't ride in open cars without eye protection.
25. Cold cream and deodorant soaps can leave residue on hands.
26. Eyelash thickeners/lengtheners have contaminating fibers/additives.
27. Waterproof mascaras are hard to remove without abrasive cleansers.
28. Don't apply eyeliner above lower lash line; it blocks glands that produce the tear film making lens wear uncomfortable.
Patient, Parent or Guardian Signature*
Consent: I understand that there is a risk involved with wearing contact lenses. I have read the above information and have been trained in the handling and care of my contact lenses and am aware of potential complications.

TSO Keller

WELCOME TO OUR OFFICE

Patient Information

VERY IMPORTANT! NEW PATIENTS ONLY:

Lifestyle Questions

Your Eye Health Information

Contact Lens History

Patient Medical History

Are you being treated for the following health problems?

Is there a family medical history of any of the following:

Authorized Access/Policies/Insurance/HIPPA

CONTACT LENS FITTING & FOLLOW-UP POLICY

Consent: I understand that there is a risk involved with wearing contact lenses. I have read the above information and have been trained in the handling and care of my contact lenses and am aware of potential complications.