You And Eye Family Eye Care registration form

Step 1 of 5

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.*
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.*
- 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

You And Eye Family Eye Care registration form

Step 1 of 5

Welcome to our office

COVID screening

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.

Patient Information

*If you do not wish to receive text messages or email notifications please VERBALLY notify a staff member so we may modify your preferences.

Privacy Policy (HIPAA)

INSURANCE BENEFITS, RECALL PROGRAM, & OFFICE BUSINESS POLICIES

DILATION CONSENT

Optomap Retinal Screening Photography

Reason for Visit

Are you currently experiencing any of the following problems with your eyes?

Patient History

Review of Systems

Please note any immediate family history (parents, siblings, children) for the following conditions: