Eyecare Form

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

List the names of people (e.g. spouse, parents, etc) you authorize us to release your health information to:

INSURANCE INFORMATION

REASON FOR TODAY’S VISIT

I currently use or have used
I have noticed a blur in vision at
I currently experience

MEDICAL & VISION HEALTH HISTORY

Eye injury/surgery
Lazy/Cross Eyes
Glaucoma
Macular Degeneration
Retinal Detachment
Retinal Disease
Diabetes
Hypertension
Heart Disease
Thyroid Disease
Cancer
Cancer
List of Medication
Allergies to Medication

REVIEW OF SYSTEMS

Cardiovascular
Psychiatric
Ear, Nose, Throat
Respiratory
Neurological
Integumentary
Gastrointestinal
Genitourinary
Hematologic
If you have a condition not listed, please explain:

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. THE FOLLOWING IS OUR OFFICE POLICIES.

Health Insurance: Please make sure we have your current and up to date insurance information. As a courtesy we will gladly file your claims and accept assignment. Although we may estimate you benefits, we are not responsible for their accuracy

Professional fees are non-refundable. Payment is expected at the time services are rendered, including any non-covered portions of insurance.

Each eyewear is made specific to your needs and glasses are processed to be made within the same business day. Refunds are only available if the lab has not started on your customized order, otherwise changes after an order is processed will be subject to 50% fee of the original price. Remakes/rechecks due to adaptation must be within 90 days of original order. Full charge will apply after 90 days.

According to the “Fairness to Contact Lens Consumers Act”, all prescriptions for contact lenses need to be re-evaluated to ensure proper fit of the lens and health of the cornea. The fitting is a separate and distinct exam from a comprehensive exam, though both may be conducted at the same visit at the discretion of the optometrist. There is a separate fee for this exam which will be collected at the time of your visit.

Contact lens follow-ups will be covered by the initial fit and evaluation fee. All follow-ups must be done within the allotted follow-up period from the initial exam to avoid additional fees. Any visit beyond the follow-up period will result in an additional $35 reassessment fee. The follow-up period will vary on the type of fitting performed.

If you are filling a prescription not written by our doctor(s), any issues with the vision must be addressed with the prescribing doctor. We, however, will do our best to make any adjustments necessary to make you as comfortable as we can. Any refraction or rechecks from us will incur a $30 fee.

If you are filling a prescription not written by our doctor(s), any issues with the vision must be addressed with the prescribing doctor. We, however, will do our best to make any adjustments necessary to make you as comfortable as we can. Any refraction or rechecks from us will incur a $30 fee.

I have read and agree to Framed Eyecare's office policies

May we have permission to take pictures of you and your NEW eyewear purchased from us to post on our social media? Your name or medical information will not be mentioned.

DILATION POLICY

The doctor highly recommends this test as part of the comprehensive eye examination. Dilation allows the doctor to fully assess the interior health of the eye with a 360 degree field of view. This procedure is important in diagnosing complications within the eye such as diabetes retinopathy, glaucoma, retinal tears or holes, macular degeneration, and more. Dilation leaves the eyes slightly sensitive to light with blurred vision for a few hours. Distance vision is rarely affected. Any additional questions can be answered by the doctor.

RETINAL PHOTO CONSENT FORM

“What are retinal photos?”
In addition to your exam and dilation, the doctor also recommends the retina/fundus camera which is a new digital retinal imaging system that now allows us to take photographs of your retina (the back of the eye). This assists the doctor in the early detection of many disorders such as glaucoma, diabetic retinopathy, macular degeneration, retinal detachments, and other vision threatening conditions. These digital images are stored in the computer and can be used to help better evaluate the optic nerve, macula, and blood vessels of the retina on a year to year basis. This allows the doctor to observe even the smallest change from the previous exams. The retinal photo is strongly recommended if any of the following apply:
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1. If you are a new patient to this office.
2. If you have never had retinal photos in this office.
3. If you are 65 or older.
4. If you have or have a family history of high cholesterol, elevated blood pressure or any circulatory disorder.
5. If you have or have a family history of diabetes or elevated blood sugar.
6. If you have headaches or visual disturbances suggestive of a neurological problem.
7. If you have or have a family history of elevated eye pressure or glaucoma.
8. If you have any retinal disorder such as a detachment, tear, floaters, veils, flashing lights, bleeding, or macular degeneration.
9. If your vision is not correctable to 20/20 in one or both eyes.
10. If you were told by your previous eye doctor of some changes in the back of your eyes.

Retinal photos are a recommended part of your eye exam if you fall into any of the above categories and does not replace the dilation. The charge for this procedure is $30.00.
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