Welcome Form Welcome, and thank you for choosing us for your eye care! We strive to provide personal and caring medical service in a respectful and private environment. Your new prescription is based on your thorough eye examination and how you’ve told us you use your eyes. To provide your best visual solution, the doctors will also provide you with lenses and lens treatments also based on how you use your eyes. If you have any questions or concerns, please do not hesitate to ask for help at any time. To help serve you better and to provide you the best eye care, please answer the following questions. Legal Name: First Middle Last Preferred First Name:Date of Birth: Legal Gender:YesNoAddress: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Work Phone:Cell Phone:Email for reminders: Patient’s Social Security #:Preferred Language:Ethnicity:Hispanic:YesNoEmployer:Occupation:Number of hours on the computer each day?Job Description:How did you hear about us?Friend/Co-workerMy doctorInsurance providerWhat site helped you make your decision?YelpGoogle/Google+Kent Eye Clinic websiteEmergency Contact: Name Relationship Phone Vision InsuranceName:ID #:Group #:Primary Holder:Relationship to patient:Social Security #:Phone:Date of Birth: Medical InsuranceName:ID #:Group #:Primary Holder:Relationship to patient:Social Security #:Phone:Date of Birth: Downloadable FormsPlease complete the forms below if you are conisdering Digital Retinal Imaging or purchasing contact lenses. Digital Retinal Imaging Form Contact Lens Fit and Follow Up PolicyFinancial Collection Policy and Authorization to Bill Your InsuranceI understand that I must pay any balances, including all co-pays and estimated portions not covered by insurance policy at the completion of today’s visit. If I have vision insurance, Kent Eye Clinic will submit my claim for me. In the case of an emergency visit or if a medical diagnosis is made, Kent Eye Clinic will submit my claim to my medical insurance. I understand that if my deductible is not met, I am responsible for the charges applied to my deductible. Although Kent Eye Clinic verifies my insurance, I understand that verification is not a guarantee of payment. Routine eye exams, refraction (glasses prescription), contact lens fitting or contact lenses, and glasses or prescription lenses may not be covered by insurance. A referral is not a guarantee of payment. I understand that it is my responsibility to know my coverage. I understand that Fundus Photos will be billed out to my medical insurance should a medical diagnosis be given by the doctor. If payment is not received by my insurance company within 60 days, I will be required to pay the balance. If I cannot pay the balance 60 days after receiving an invoice, a 2.3% fee will be added to the invoice each month until Kent Eye Clinic receives full payment. Patients without insurance are given a 20% discount on their exam and glasses order if they are to pay in full on the same day. I authorize my insurance benefits to be paid directly to the physician. I also authorize the doctor to release any information and medical records required by my insurance company. No other records shall be released without my signed consent. I also consent to receive communication via electronic mail. These communications will be infrequent and may include appointment reminders and/or special events that may benefit me. We will not share, sell, rent, swap, or authorize any third party to use your email address for commercial purposes. I agree to the terms listed above. Patient/Guardian Signature:Date: Health Insurance Portability Accountability Act AcknowledgementI understand that as part of my health care, Kent Eye Clinic originates and maintains paper and/or electronic records describing my health history, symptoms, examinations and test results, diagnosis, treatment, and any plans for future care of treatment. I understand that this information serves as: • A basis for planning my care and treatment • A means of communication among the many health professionals who contribute to my care • A source of information for applying my diagnosis and treatment information to my bill • A means by which a third-party payer can verify that services billed were provided I understand that I have the following rights and privileges per the Notice of Privacy Practices (this document is available upon request): • The right to review the notice prior to signing this consent • The right to object to the use of my health information for directory purposes • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations. I understand that Kent Eye Clinic is not required to agree to these restrictions requested. I understand that I may revoke this consent in writing, except to the extent, that the origination has already acted in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that Kent Eye Clinic reserves the right to change their notice and practices, and prior to implementations, in accordance with Section 164.520 of the Code of Federal Regulations. Should Kent Eye Clinic change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. Mail or, if I agree, email).I wish to allow the disclosure of my health information to the following person(s):NameRelationship I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosures for these permitted uses including disclosures via fax. BY SIGNING BELOW, I ACCEPT THE ABOVE STATEMENT AND TERMS OF THIS CONSENT. Patient/Guardian Signature:Date: Thank you for choosing our practice for your eye care! To ensure privacy, respect, and courtesy to our patients we enforce the following acknowledgements and policies. As always, please do not hesitate to ask if you have any questions or concerns. Please initial below that you have read and agree to the following:Initial:We value your time. We try our very best to stay on schedule, but sometimes emergencies arise. If we are seriously delayed, you will be notified. Initial: Please turn your cell phones off or on vibrate. Please be courteous to other patients by not using your cell phone in the reception area or doctor’s office.Initial:If you are unable to make your appointment for any reason, please feel free to reschedule as soon as possible. There is a $39 no show / same day cancellation fee. Initial:Payment of co-pays, deductibles, or any balances not covered by insurance is due at time of service. If you are being seen today, payment is due today. Initial: Dilation: Comprehensive exams include dilation to detect eye disease. Dilation with eye drops will approximately last 1 – 4 hours. You will experience sensitivity to light and blurry near vision. If you did not bring dark glasses, we will provide a disposable pair. If you do not want to be dilated you may opt out by taking a digital retinal photo (fundus) and iWellness scan for $39. Initial: Glasses (Lenses and Frame): Glasses are custom made for you and only you. There is a 20% restocking fee for any changes or cancellations. If you are experiencing issues with your glasses, we’re here to help! Please let us know within 30 days of pick up so we can act accordingly. Payment in full is required before glasses can be picked up. Initial: As required by law, all minors under the age of 18 must be accompanied by an adult. Initial: Strike a pose! During your visit, you may be asked to pose for a photo. Posing for a photo to be used on social media or our website constitutes consent to use your image. No personal information, such as your name, etc. will be used with your image. Patient Health InformationPrimary Care Doctor/Location:Last Eye Exam:(number of years)Reason for today’s visit:(routine, blurred vision, eye irritation)Please list your medications and dosage:(including vitamins, creams, inhalers, sprays, and injections, including eye medications)MedicationDosage Any allergies to medications?Name/Location of primary pharmacy:Would you like to see without glasses?YesNoAre you interested in being fitted for contact lenses, or in having your contact lens prescription renewed?Are you interested in learning about LASIK?Are you interested in information on cataract surgery?Do you experience any of the following symptoms? Computer-related eyestrain Halos while driving at night Sensitivity to sunlight Other If other, please specify:Do you enjoy any of these activities? Camping / Hiking / Travel Sailing / Fishing / Snow / Golf Other If other, please specify:Do you wear makeup?YesNoIf yes, how do you remove it?Patient Ocular History:(please check any that apply) Glaucoma Blindness Cataract Surgery Eye Injury Macular Degeneration Retinal Detachment Prosthetic Eye Cataract Retinal Hemorrhage Strabismus (crossed eye) Amblyopia (lazy eye) Dry Eyes Glasses Contact Lenses Other If glasses, please specify:Part-timeFull-timeIf contact lenses, please specify the brand:If other, please specify:Patient Medical History:(please check any that apply) High Blood Pressure Dizziness Skin Cancer Migraines Bell’s Palsy Meniere’s Disease Stroke Hepatitis Epilepsy Lupus Heart Disease Basal Cell Carcinoma Dementia Cerebral Palsy Depression High Cholesterol Crohn’s Disease Fibromyalgia Sarcoidosis Asthma Diabetes Type I Dialysis Rheumatoid Arthritis Arthritis Cancer Diabetes Type II Sjogren’s Syndrome Bronchitis Anemia Vertigo Hypothyroidism Pneumonia Emphysema Sinusitis Psoriasis Hyperthyroidism Other If other, please specify:Family Medical History:(please check any that apply) High Blood Pressure Glaucoma Retinal Disease Eye Injury Diabetes Hypertension Macular Degeneration Cataracts High cholesterol Amblyopia (lazy eye) Prosthetic Eye Cancer Heart Disease Heart Defect Blindness Other If other, please specify:Social History: Tobacco Alcohol Drugs If tobacco, how much and how often?If alcohol, how much and how often?If drugs, how much and how often?