Patient Registration – English Practice LocationWhich Location will you be visiting?*North DenverAuroraMontbello/Green ValleyWestminsterPatient InformationName* First Last Date of Birth* Date Format: MM slash DD slash YYYY Age*Gender*MaleFemaleAddress Street Address Address Line 2 City State ZIP / Postal Code Home Phone NumberCell Phone NumberEmail Approximate Date of Last Eye Exam* Date Format: MM slash DD slash YYYY What Brings You to Our Office?*Please select all that apply. Routine Eye Exam Want Contact Lenses Want Glasses Burning Eye(s) Double Vision Eye Infection Eye Strain Flashes/Floaters Glare Headaches Red Eye Tearing Do you have other concerns that were not listed above?Do you wear glasses?*YesNoWhat type of glasses do you wear?DistanceReadersLined Multi-focalProgressivesDo you wear contact lenses?*YesNoWhat brand of contact lenses do you wear?What type of contact lenses do you wear?Daily DisposablesWeekly DisposablesMonthly DisposablesToricHard or Gas PermeableBifocal or Mono VisionEye Health: Do you now or have you ever had an eye issue?*Please select all that apply. Cataracts Eye Injury Eye Surgery or LASIK Glaucoma Keratoconus Lazy Eye (Amblyopia) Macular Degeneration Strabismus (Eye Turn) Vision Therapy Do you now or have you ever had other eye health issues that were not listed above?Have you been diagnosed with a health issue?*Please select all that apply. Allergies/Hay Fever Arthritis Cancer Diabetes Heart Disease High Cholesterol High Blood Pressure HIV/AIDS Pregnant/Nursing Thyroid Disease Do you now or have you ever had other health issues that were not listed above?Are you allergic to any medications?*YesNoPlease List Allergies List All Current Medications*MedicationDosageFrequency List Any Family Medical History*Only list family members who are related to you by blood.RelationHealth Issue Do you use or have used tobacco products?YesNoHow long have you been using or did use tobacco products?Retinal Exam: Dilation or Optos®Our practice recommends having your eyes dilated or scanned at every annual visit.Dilation Drops are used to enlarge the pupil, allowing the doctor to see a more complete view of the retina. The drops will cause light sensitivity and blurred vision, especially up-close, for approximately four to six hours. This will add approximately 30 minutes to your exam.Optos Retinal Imaging Optos is a fast, painless, and comfortable digital imaging of the retina. The Optos allows your doctor to confirm your retinal health, or discover signs of abnormalities. It provides a permanent record of your retina that can be compared and/or reviewed at next year’s exam. Drops are not required in most cases. This is the Doctor’s preferred method and a copy of the image can be made available to you. Optos is an additional $39.00 fee that is not normally covered by vision insurance.Please Select an Option Below*Optos Retinal Imaging at the cost of $39DilationDecline Dilation and OptosConsent*I understand that these procedures are recommended as appropriate for me and if I elect to decline both dilation and digital imaging, my doctor will not be able to adequately assess for retinal pathology, optic nerve disease, or other anomalies. I understand my choice and how it relates to my eye health.Vision InsurancePlease bring all insurance cards with you to your appointment.Do you have vision insurance?*YesNoVision Insurance ProviderPolicy Holder's Name First Last Policy Holder's Date of Birth Date Format: MM slash DD slash YYYY Relationship to Policy HolderPolicy Holder's EmployerPolicy Holder's Member ID#Medical InsurancePlease bring all insurance cards with you to your appointment.Medical Insurance ProviderPolicy Holder's Name First Last Policy Holder's Date of Birth Date Format: MM slash DD slash YYYY Relationship to Policy HolderPolicy Holder's EmployerPolicy Holder's Member ID#AcknowledgmentsPatient Notification – Consent to Treatment Please be advised that if you are being seen today for a Routine Eye Exam that based upon any of the following concerns – family history, current medical disease and/or conditions, chief complaint, pre-test findings – the Doctor may find it necessary to bill your exam medically as well as order additional tests. You will be notified during the course of the exam if medical billing is necessary. Exams billed medically are not covered under your Routine Eye Exam benefits or Vision Insurance Plan. If a medical issue exists, your exam will be billed medically through your Medical Insurance Carrier and are subjected to their specific co-pays, deductibles, and co-insurance which will be due at the time of service. In the event you want a routine examination for your eyeglasses or contact lens prescription, you understand it is your responsibility to immediately inform the Doctor so that they can refer you to the appropriate Specialist for any medical concerns.Financial Acknowledgment I hereby authorize any person/institution rendering care to furnish all facts concerning this claim. I authorize payment for my vision benefits and/medical benefits to go directly to the practice. I authorize the practice to deposit checks received on my account made out to me for services rendered. I agree that if my employer, insurance carrier or plan sponsor denies payment to all or any portion of my claim, I will be financially responsible for all outstanding charges. Authorization obtained at the time of service does not guarantee payment and any denied services will be balanced and billed to the patient. Patients with insurance must present their information to us prior to any service(s)/purchase(s). We will not bill the insurance after the service(s)/product(s) are already performed, therefore there will be no refund! You may send the receipt to your insurance company and try to get reimbursed yourself. In the case that a return is needed, there will only be store credit. No monetary refund will be given.HIPAA Compliance and Release of Information The practice is subject to State and Federal regulations. The practice and/or its doctor may disclose all or any part of the patient’s record for this service to any person or corporation which is or may be liable under a contract to the Optometrist, or to a family member or employer of the patient for all or part of the provider’s charges, including, but not limited to hospital or medical service companies, insurance companies, worker’s compensation carrier, welfare funds and all authorized auditors as specified in the Insurance Carrier Guidelines and referring professionals. The practice follows HIPAA guidelines. A full detailed report of the practices’ Notice to Privacy Practices is available upon request.Consent*I have read the “Consent to Treatment”, “Financial Acknowledgement”, and “HIPAA Compliance and Release of Information” as the Patient, or the Patient authorized representative or general Agent for the purpose of signing this document, hereby accept its terms. I have read and understand.Signature*
