Existing Patient Forms Step 1 of 3 - Medical Information 33% Medical HistoryVision plans cover “routine” eye exams. Some medical plans will only cover the visit if there is a medical reason for the visit, such as loss of vision, eye redness, eye discomfort, dry eyes, glaucoma, cataracts, floating spots, etc. If we are able to use your medical insurance to cover the visit, you will have to pay both the specialist copay as listed on your insurance card and the refraction fee (refraction is the part of the exam that determines your eyeglass prescription) We will help as much as possible to determine coverage, but ultimately, you are responsible for referrals and fees not covered or applied to your deductible. For current contact lens wearers or those who want to be fit for contact lenses, there is an additional fee (other than the eye exam fee) for the evaluation and measurements necessary to determine the health, safety and proper lens selection for the eyes. This includes any wearing instructions, starter solutions/kits, and any follow-up visits to complete the fitting/evaluation, as determined by the doctor. These measurements and lens needs can change and will need to be re-evaluated over time.Name First Last Date MM slash DD slash YYYY Please initial that you understand the above statements:Are you interested in purchasing new glasses today? Yes No Do you currently wear contact lenses? Yes No Are you interested in contact lenses? Yes No Are you interested in Laser Vision Correction? Yes No REASON for VISIT: How can we help you today? Please tell us below the main eye/vision problem that you are having:Are there any associated symptoms? Does anything alleviate the symptoms? Review of Systems:Do you or any family member have or ever had the following? (Please check if “Yes”)YouFamilyYou and FamilyAllergiesArthritisAsthmaAutoimmune DisorderCancerDiabetesGastrointestinal DiseasePsychiatric DisordersThyroid DiseaseGlaucomaLazy EyeHeadacheHeart DiseaseHigh Blood PressureHigh Cholesterol Lung ProblemsNeurological ProblemsGenito/UrinarySkin ConditionsEye/Head Injury Eye SurgeryOther Eye DiseaseGender? Male Female Are you pregnant? Yes No Are you nursing? Yes No Please list any medications you are taking now: Are you a: Current Smoker Former Smoker Never Smoked Alcohol use: Socially Daily Use Never Any drug allergies? No Yes Wellness CheckName First Last Date MM slash DD slash YYYY For the safety of other customers and our employees, let's first get these familiar questions out of the way. Please answer this brief COVID-19 questionnaire for the person being scheduled. All fields are required. In the past 14 days, have you tested positive for COVID-19? Yes No In the past 14 days, have you been in close contact with anyone who tested positive for COVID-19? Yes No Do you currently have fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea? Yes No Optos ConsentDuring a comprehensive eye exam our doctors need to evaluate the overall health of your eye. With the optomap® Retinal Exam, they can screen for retinal complications including macular degeneration, glaucoma, and retinal holes or detachments. This screening procedure can also detect problems unrelated to the eye that may show signs in the retina such as diabetes, hypertension, cancer/tumors, auto-immune disorders, and others, earlier than possible with traditional methods. For more information about the importance of Optomap, please Click here The optomap® Retinal Exam: ✔ Is as fast as taking a picture. It also will reduce time and contact in the exam room. ✔ DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, avoiding side effects such as blurry vision and light sensitivity. ✔ Saved in your file enabling our doctors to make important comparisons during your annual eye exam. There is a $35.00 fee for the optomap® Retinal Exam.Please make your selection* I understand that the optomap retinal exam will be performed today and do not have any questions. I do NOT want to have this test done. Name First Last SignatureDate MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.