Patient Name:(Required)

First Last

D.O.B:(Required)

MM slash DD slash YYYY

Sex:(Required)

Patient Email:(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Preferred Pharmacy:(Required)

Address:(Required)

VISION PLAN

Insurance Plan Name:(Required)

Member ID #(Required)

Group #:(Required)

Primary Card Holder:(Required)

D.O.B:(Required)

MM slash DD slash YYYY

Primary Card Holder SSN:(Required)

Relationship to Patient:(Required)

PRIMARY INSURANCE PLAN

Insurance Plan Name:(Required)

Member ID #:(Required)

Group #:(Required)

Primary Card Holder:(Required)

D.O.B:(Required)

MM slash DD slash YYYY

Primary Card Holder SSN:(Required)

Relationship to Patient:(Required)

DILATION AND ADDITIONAL TESTS

We are pleased to provide our patients with an advanced scanning laser photo system called Optomap. This allows the doctor to screen for diabetes, glaucoma, and other diseases without dilation drops. OTHERWISE WE REQUIRE ALL PATIENTS TO BE DILATED(Required)

I agree to have Optomap photos instead of dilation. I understand the fee is $39.

I agree to dilation

Please check the box below if you would like a peripheral vision field screening. This test is very helpful in detecting visual defects that may occur such as in glaucoma, diabetes, and/or macular degeneration.

I agree to the visual field screen screening. I understand the fee is $20.

PRIVACY PRACTICES ACKNOWLEDGEMENT AND RECEIPT

Due to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the following information must be completed and updated annually by the patient or guardian:
In the event a family member or caregiver attends my office visits and is in the exam room at the time of my evaluation and/or treatment, I give Cedar Park Eye Care providers and employees my permission to discuss freely my condition, treatment or diagnosis with that person present.

Yes

By signing below, I acknowledge that I have been provided a copy of this facility's Notice of Privacy Practices Form (Rev. 10/2019) for review and a personal copy to keep will be provided upon request. If you have any questions about this notice, please contact the Facility Privacy Officer at (512)249-0808.

Signature of Patient or Guardian:(Required)

Date(Required)

MM slash DD slash YYYY

Relationship to Patient:(i.e., Self, Parent)(Required)

PERSONAL HEALTH INFORMATION RELEASE (PHI)

This release authorizes Cedar Park Eye Care to discuss medical information regarding my care, lab or imaging results, condition, treatment or diagnosis, and account information with the following:(Required)

Patient only

Other:

Relationship:(Required)

Phone(Required)

The following people may pick up medication samples and/or prescriptions on my behalf:(Required)

Patient only

Other:

Relationship:(Required)

Phone(Required)

Signature of Patient of Guardian:(Required)

Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Relationship to Patient:(i.e., Self, Parent)(Required)

MEDICAL HISTORY

Date

MM slash DD slash YYYY

When was your last eye exam?

When was your last medical exam?

Referring Doctor (letters, etc.)

Do you have any of the following medical conditions? (Self, Father, Grandmother, Daughter, Etc.)

Cataract

Patient

Other

Who

Glaucoma

Patient

Other

Who

Macular Degeneration

Patient

Other

Who

Retinal Detach/ Disease

Patient

Other

Who

Lupus

Patient

Other

Who

Heart Disease

Patient

Other

Who

Seizure Disorder

Patient

Other

Who

Crossed Eyes

Patient

Other

Who

Arthritis

Patient

Other

Who

Diabetes Type 1 or 2

Patient

Other

Who

High Blood Pressure

Patient

Other

Who

Cancer

Patient

Other

Who

Lazy Eye

Patient

Other

Who

Thyroid Disease

Patient

Other

Who

Keratoconus

Patient

Other

Who

Dry Eyes

Patient

Other

Who

Have you had any medical surgeries in the past?

Yes

Please list them here:

Do you wear glasses?

Yes

how old are your glasses?

Do you wear contact lenses?

Yes

what kind of contacts

Rigid

Soft

Hybrid

How often do you replace your contacts?

Are they comfortable?

Yes

How many hours are you on the computer each day?

Are you interested in information regarding LASIK?

Yes

Do you take any medications, vitamins, or supplements?

Yes

please list them here:

Have you had LASIK or Cataract surgery in the past?

LASIK

Cataract

When?

Do you have any allergies?

Yes

please list them here:

Do you use any tobacco, cigarette, or e-cigarette products?

Yes

what kind and how often?

Do you drink alcohol?

Yes

how often?

Please check all that apply:

Eyes:

Poor vision

Eye Pain

Tearing

Redness

Jaw Pain

Scalp Tenderness

Amaurosis Fugax

Loss of Vision

Constititional:

Fever

Chills

Weight Loss

Respiratory:

Cough

Congestion

Wheezing

Shortness of Breath

ENT and Mouth:

Stuffy Nose

Ear Ache

Dry Mouth

Cardiovascular:

Rapid Heart Beat

Gastrointestinal:

Upset Stomach

Diarrhea

Constipation

Burning on Urination

Urinary Frequency

Incontinence

Musculoskeletal:

Joint Pains

Stiffness

Integumentary:

Changing Moles

Rash

Neurological:

Headache

Seizure

Stroke

Paralysis

Psychiatric:

Anxiety

Depression

Insomnia

Endocrine:

Thyroid Abnormalities

Hematologic:

Bleeding

Anemia

Immunologic:

Allergies

Hay Fever

Hives

Other:

Artificial Heart Valve

Artificial Joints(within 2 years)

Blood Thinners

Narrow Angles

Pregnancy

Pseudoexfoliation Syndrome

Elevated Blood Sugar

COVID-19 Waiver

By signing this form you acknowledge that you do NOT have any of the following symptoms or have done any of the following activities. I have not been in close contact with or cared for someone diagnosed with COVID-19 within the last 14 days. I have not experienced any of the following cold or flu-like symptoms in the last 14 days: - excessive cough, fever, sore throat, shortness of breath

x(Required)

Eyeglass Purchases & Contact Lens Wearers

Please be advised if you would like a prescription for contact lenses, you are responsible for a contact lens examination every year which includes 90 days of follow up care. This fee is an addition to your glasses examination & varies depending on the type of contact lens fitted and is assessed by the doctor during your examination. Glasses purchased have a 90 day remake policy from date of purchase for lenses only. A 25% restocking fee will be assessed for all cancelled orders.

x(Required)

Financial Responsibility

I authorize payment of my medical benefits to the undersigned physician / supplier for services rendered and/or products provided. I understand that Cedar Park Eye Care will make every effort possible to bill my insurance company and obtain all the necessary information for proper billing in advance of the services. I also understand that if Cedar Park Eye Care is unable to obtain authorization from my insurance company or if my insurance company fails to cover the services and materials, I WILL BE PERSONALLY FINANCIALLY RESPONSIBLE FOR SERVICES RENDERED AND PRODUCTS DELIVERED AND/OR PROVIDED. I am responsible for all accounting fees in the event of my non-payment. There is a $50 no-show and cancellation policy in effect if no notice given within 24 hours of your visit and $50 returned check policy.

x(Required)

Annual Contact Lens Agreement

- If your Rx changes, we will exchange contact lenses purchased from us. Boxes must be resalable, i.e. no marks, no writing, no torn or missing labels and must be factory sealed. - Contact Lenses are medical devices which should be monitored by the doctor to determine the current prescription and health of the eyes to ensure successful contact lens wear. - I understand that annual exams and sometimes 6 month corneal evaluations are necessary to continue replacing contacts. - I understand that there is an increased risk of infection, corneal ulcers that can lead to loss of vision or blindness with contact lens wear. The risk increases significantly if the contacts are worn while sleeping, either 10 minutes or 10 hours. Complying with wearing times, care regimens and disposal schedules minimize this risk. - I understand that if sudden or prolonged redness, pain or irritation of the eyes occurs, I should remove the lenses and call this office immediately. - I understand that topping off the solution in my case every night instead of replacing it can lead to permanent vision loss.

x(Required)