Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Reason for Visit: Secondary Reasons:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam:

Primary Vision Correction:
Do you have back up glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye:

Medications: Over The Counter Medications:
Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:

Family Medical History



Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Submit Form / Patient Signature



INFORMED CONSENT FOR RETINAL EVALUATION

Proper assessment of the internal health of your eye is done to detect many vision problems and systemic diseases (such as diabetes and high blood pressure). We can assess the eyes by instilling drops to relax the muscles or via the OPTOPMAP that takes a picture of the back of the eye (the retina). If you prefer to be dilated we will instill drops into the eye which enlarges the pupils. As a result, there is some blurring of the near vision and light sensitivity for approximately four to six hours.

The Retinal Photography exam is fast, easy, and comfortable. It is utilized as an alternative to the pupil dilation. It allows the doctor to check for most retinal conditions without the need for dilation. There are no side effects because it is as simple as snapping a picture. Our high tech OPTOMAP is able to capture a digital photo of your retina.

We highly recommend either the retinal photography or dilation of the eyes as part of a comprehensive eye exam. The dilation is $10 and the Retinal Photography is $30.00.

Yes, I consent to having a Retinal Photography exam.

Yes, I consent to having a Dilated Retinal exam.

No, I understand the risks and refuse a retinal evaluation.

Patient Signature: Date:

HIPPA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION under the HIPPA Rule of 2013.

For purposes of this Notice "us" "we" and "our" refers to the Name of this healthcare facility: Spectrum Vision and "you" or "your" refers to our patients (or their legal representatives as determined by us in accordance with state informed consent law). When you receive healthcare services from us, we will obtain access to your medical information (i.e. your health history). We are committed to maintaining the privacy of your health information and we have implemented numerous procedures to ensure that we do so.

The Federal Health Insurance Portability & Accountability Act of 2013, HIPPA Omnibus Rule, (formally HIPPA 1996 & Hi Tech of 2004) require us to maintain the confidentially of all your healthcare records and other identifiable patient health information (PHI) used by or disclosed to us in any form, whether electronic, on paper, or spoken, HIPPA is a Federal Law that gives you significant new rights to understand and control how your health information is used. Federal HIPPA Omnibus Rule and state law provide penalties for covered entities, business associates, and their subcontractors and records owners, respectively that misuse or improperly disclose PHI.

Starting April 14,2003, HIPPA requires us to provide you with the Notice of our legal duties and the privacy practices we are required to follow when you first come into our office for healthcare services. If you have any questions about this Notice, please ask us.

Our doctors, clinical staff, employees, Business Associates (outside contractors we hire), their subcontractors and other involved parties follow the policies and procedures set forth in the Notice. If at this facility, your primary caretaker/ doctor is unavailable to assist you (i.e. illness, on-call coverage, vacation, etc.), we may provide you with the name of another healthcare provider outside our practice for you to consult with. If we do so, that provider will follow the policies and procedures set forth in this Notice or those established for his or her practice, so long as they substantially conform to those for our practice.

OUR RULES ON HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

Under the law, we must have your signature on a written, dated Consent Form and/or an Authorization Form of Acknowledgment of this Notice, before we will use or disclose your PHI for certain purposes as detailed in the rules below.

Documentation- You will be asked to sign an Authorization/ Acknowledgment from when you receive this Notice of Privacy Practices. If you do not sign such a form or need a copy of the one you signed, please inform us.

By signing below, I agree that I have reviewed and understand the information above:

Patient Signature: Date:
Patient Representative: