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You And Eye Family Eye Care registration form
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2020-12-29T21:32:55+00:00
You And Eye Family Eye Care registration form
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Welcome to our office
It is our true pleasure to have you here today. We strive to offer patient-centered eye and vision care. Please complete the following to help us get to know you, and tailor your exam to your exact needs.
COVID screening
Have you had fever, cough, sore throat, nausea, vomiting, shortness of breath or loss of taste and smell in the past 14 days?
*
Yes
No
Have you been exposed to someone with the flu or coronavirus in the last 14 days?
*
Yes
No
Myself, and/or someone living in my immediate household has traveled outside the state within the past 14 days?
*
Yes
No
If you responded YES to any of the above 3 queries, we kindly ask that you reschedule your exam, for the safety of our patients, staff, and visitors.
By signing this form, I agree that I will not hold You and Eye Family Eye Care or any of its doctor’s or staff personally responsible should I, or someone I come in contact with, become positive or presumptively positively diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge You and Eye Family Eye Care and its doctors and staff for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.
*
Today's Date
*
MM slash DD slash YYYY
Patient Information
Patient's Name
*
First
Last
Date of birth
*
MM slash DD slash YYYY
Cell Phone
*
Email
*
Preferred Method of Contact
*
Cell Phone
Text Message
Email
*If you do not wish to receive text messages or email notifications please VERBALLY notify a staff member so we may modify your preferences.
Notice of Privacy Practices: In signing this authorization to release my protected health information, I acknowledge that I understand my right to medical information confidentiality and authorize You and Eye Family Eye Care Center to discuss all my medical health information with the individual)s) listed below:
*
Yes, I want to share my health information
No, I do not want to share my health information with anybody at this time
Name of Individual
*
First
Last
Relationship to:
*
Cell phone number
*
Patient Signature
*
Privacy Policy (HIPAA)
I acknowledge that I have either been given access to and reviews or received a copy of the Office's Notice of Privacy Practices, ("Notice") which describes how my health information is used and shared. I understand that the Office has the right to change this Notice at any time. I may obtain a current copy by contacting the Office Privacy Officer.
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FOLLOW THIS LINK TO VIEW OUR NOTICE OF PRIVACY PRACTICES
Date
MM slash DD slash YYYY
Date
MM slash DD slash YYYY
INSURANCE BENEFITS, RECALL PROGRAM, & OFFICE BUSINESS POLICIES
I, the undersigned may have insurance coverage and/or vision plan coverage with an insurance carrier(s) or vision plan and assign directly to Bhend Family Eye Care PLLC dba You and Eye all medical, vision plan and/or surgical benefit, if any, otherwise payable to me for services rendered. I hereby request that Bhend Family Eye Care PLLC dba You and Eye to file any claim(s) for medical and/or preventative care benefits with my medical carrier prior to filing a claim(s) with any vision carrier or free standing vision plan unless I indicate otherwise at time of service. I hereby authorize the release of all information necessary to secure the benefit of payment of benefits As part of Dr. Bhend’s annual recall program, I authorize Bhend Family Eye Care PLLC dba You and Eye to utilize my name, mailing address, phone number, email address, and next appointment date & time to Bhend Family Eye Care PLLC dba You and Eye for the purpose of providing annual reminder postcards, coupons, and product information. I understand that: I am financially responsible for all charges whether or not paid by insurance or vision plan; co-pay, co-insurance, and deductibles are due at time of service; contact lens fitting fees, which are not generally covered by insurance not a part of a routine eye exam are due at time of service; Bhend Family Eye Care PLLC dba You and Eye charges $30.00 for any check returned from your bank; returned check fees will be added to my unpaid balance and must be paid by credit card or in cash. Contact lens fitting fees are good for 90 days from date of original contact lens fitting; any contact lens fitting not completed in 90 days may incur additional fees.
Signature
Date
MM slash DD slash YYYY
DILATION CONSENT
Dilation is the only way 100% of your retina can be seen and can also help reduce the effects of your or your child’s focusing which allows for a more accurate prescription. Dilation has no additional charge at this time.
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I consent to dilation during my exam
I decline dilation at this time. I understand that the doctor may not get a complete view of the health of my eye.
Dilation consent signature
Date
MM slash DD slash YYYY
Optomap Retinal Screening Photography
While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough screening of the retina is critical to verify that your eye is healthy. This can lead to early detection of common diseases, such as glaucoma, diabetes, macular degeneration, and even cancer. The photos are quick, painless, and may not require dilation drops. More than 80% of your retina can be evaluated in one single image while traditional imaging methods typically only show 15% of your retina at one time. These photos will become a part of your medical records and will allow the doctor to compare them with subsequent photos at future exams in order to detect even the smallest amounts of change.
There is an additional $39.00 screening fee for the Optomap retinal photo. This is not covered by insurance, but may be reimbursable by health savings/reimbursement accounts. Dr. Bhend highly recommends for complete retinal evaluation.
*
I consent to optomap screening during my exam
I decline retinal screening and dilation at this time. I understand that the doctor may not get a complete view of the health of my eye
Optomap retinal photo consent signature
Date
MM slash DD slash YYYY
Reason for Visit
Do You Wear Glasses?
*
Yes
No
How old are your present glasses?
*
Do you plan to purchase glasses at your appointment?
*
Yes
No
Do You Wear Contacts?
*
Yes
No
Have you worn contacts before?
*
Yes
No
How often do you wear your contacts?
*
Part-time / Socially
Full-time
How often do you throw away your contacts?
*
What solution do you use for your contact?
*
How many hours a day do you use a computer?
*
How many hours per day are you exposed to bluelight? (i.e screens, phones, tablets)
*
What eye concerns bring you in to see Dr.Bhend today?
*
Are you currently experiencing any of the following problems with your eyes?
Blurred Vision
With correction
Without correction
Blurred vision for which eye(s)?
Right
Left
Both
At which focal point does your blurred vision occur? (I.e. computer, near and/or distance)
Do you have blurred vision with?
Glasses
Contacts
Do you experience eye strain with your blurred vision?
Yes
No
Does your blurred vision fluctuate when blinking?
Yes
No
Headaches
Yes
No
Your headaches are long standing or new?
Long standing
New
Location of the headaches?
Time of day of the headaches?
Trigger or activity associated with the headaches?
Dry Eye (Burning / Stinging / Tearing)
Yes
No
Time of day of the dry eye?
Dry eye for which eye?
Right
Left
Both
Do you use any of the following for dry eyes (check all that apply)
Warm compress
Lid scrubs
Drops
Floaters
Yes
No
Floaters are stable, increased or decreased?
Stable
Increased
Decreased
Floaters for which eye?
Right
Left
Both
Flashes
Yes
No
Flashes are stable, increased or decreased?
Stable
Increased
Decreased
Flashes for which eye?
Right
Left
Both
Flashes visible with eyes open or closed?
Open
Closed
How long are the flashes lasting?
Halos / Glare
Yes
No
Light Sensitivity
Yes
No
Patient History
I am a returning patient and have no changes from our last annual visit
Review of Systems
Consent
I decline having any of the following conditions
Constitution
*
All Normal
Developmental disability
Cancer
Fatigue Syndrome
Ear, Nose & Throat
*
All Normal
Hearing Loss
Sinusitis / Sinus Pain
Dry Mouth
Laryngitis
Neurological
*
All Normal
Multiple Sclerosis
Epilepsy
Cerebral Palsy
Tumor
Stroke/CVA
Migraine
Autism Spectrum Disorder
Psychiatric
*
All Normal
Depression
Attention Deficit
Anxiety Disorder
Bipolar Disorder
Cardiovascular/Cardiac
*
All Normal
High Blood Pressure
Stroke / CVA
Heart Disease
Vascular Disease
Congestive Heart Failure
Respiratory
*
All Normal
Cigarette smoker
Asthma
Bronchitis
Emphysema
Chronic Obstruction
Sleep Apnea
Gastrointestinal (GI)
*
All Normal
Chron's Disease
Colitis
Ulcers
Acid Reflux
Celiac Disease
Genitourinary
*
All Normal
Kidney Disease
Prostate Disease/Cancer
STD - Herpetic/ Chlamydia
Benign Prostate Hypertrophy
Pregnant or Nursing
Musculoskeletal
*
All Normal
Osteoarthritis
Arthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Osteoporosis
Gout
Integumentary (Skin)
*
All Normal
Eczema
Rosacea
Psoriasis
Herpes SImplex/Cold Sores
Herpes Zoster/Shingles
Endocrine
*
All Normal
Type 2 Diabetes Mellitus
Type 1 Diabetes Mellitus
Thyroid Dysfunction
Hormonal Dysfunction
Hematologic/Lymphatic
*
All Normal
Anemia
Large-volume blood loss
Ulcer
High cholesterol
Allergic/Immune
*
All Normal
Drug Allergies
Environmental Allergies
Rheumatoid Arthritis
Lupus
Sjogren's Syndrome
If you checked any of the above boxes or have a condition not listed, please explain further:
Are you allergic to any medications?
*
Yes
No
Which ones?
*
Do you have any environmental allergies? If yes, please explain
*
Do you have a latex allergy?
*
Yes
No
List any medications you are currently taking (include oral contraceptives, aspirin, over the counter medications)
*
Have you been diagnosed with any of the following? Check the box if yes.
*
Cataracts
Crossed Eyes
Eye Injury
Glaucoma
Lazy Eye/Amblyopia
Macular Degeneration
Retinal Detachment
Dry Eye
Other
No Eye Diagnoses At This Time
Please Specify
*
Have you had refractive surgery?
*
Yes
No
What date and type?
*
Do you use alcohol:
*
Yes
No
Do you use tobacco products?
*
Yes
No
Please note any immediate family history (parents, siblings, children) for the following conditions:
Cancer
None
Mother
Father
Sister
Brother
Son
Daughter
Type 1 Diabetes
None
Mother
Father
Sister
Brother
Son
Daughter
Type 2 Diabetes
None
Mother
Father
Sister
Brother
Son
Daughter
High Blood Pressure
None
Mother
Father
Sister
Brother
Son
Daughter
Hyperthyroid Disease
None
Mother
Father
Sister
Brother
Son
Daughter
Hypothyroid Disease
None
Mother
Father
Sister
Brother
Son
Daughter
Cataract
None
Mother
Father
Sister
Brother
Son
Daughter
Macular Degeneration
None
Mother
Father
Sister
Brother
Son
Daughter
Glaucoma
None
Mother
Father
Sister
Brother
Son
Daughter
Other
None
Mother
Father
Sister
Brother
Son
Daughter
Please Specify condition
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