Online Patient Form

Click here to return to the previous website.

After completing all the forms, please submit your data on the final tab. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
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

Who may we thank for your referral?:



Medical History

Do you have a history of any of the following?:

   Yes   No
Cataracts   
Eye Turn   
Glaucoma   
Keratoconus   
Lazy Eye   
Macular Degen   
Retinal Detach   
Eye Surgery   

General Eye/Health History

   Yes   No
Headaches   
Glare/Light Sensitivity   
Styes/Eye Infection   
Flashes/Floaters in Vision   
Blurred Vision   
Double Vision   
Dry Eyes/Burning Eyes   
Redness/Itching   
Excess Tearing/Water   
Sandy/Gritty Feeling   
   Yes   No
Diabetes      
Endocrine/Thyroid      
Allergies/Hay Fever      
High Blood Pressure      
High Cholesterol      
Blood/Lymph Condition      
Gastrointestinal Illness      
Kidney/Bladder Condition      
Skin Condition      
Other

Any Allergies?:
Any Medications/Vitamins/Supplements?:

Last Eye Exam: Office:
Primary Care Physician: Office:

Height: ft. in.
Weight: lbs.

Family History

Any history of the following in any family members (parents, grandparents, siblings, children)?:

   Yes   No   Relationship
Poor Vision   
Blindness   
Eye Turn   
Lazy Eye   
Glaucoma   
Cataracts   
Macular Degen   
Retinal Disease   
   Yes   No   Relationship
Cancer   
Diabetes   
High BP   
High Cholesterol   
Stroke   
Thyroid Disease   
Other Inherited Disease   
If yes, what disease?    

Social History

Smoking Status: How often do you consume alcohol: Recreational Drugs:
Race: Ethnicity:

Submit Data

Medical Release Of Records

Date Of Request:
Patient Name:
Date Of Birth:

I hereby authorize the release of the information indicated below:

All Records Eye Examination Only Medical Records Only
Photos Diagnostic Testing Other


This authorization may be revoked at any time. The only exception is when action has been taken in reliance on the authorization. Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonable needed to complete the request.

Patient Signature: Date:
Information Requested To Be Sent From PH
Fax

Optomap/Dilation

In order to more fully examine the health of the inside of the eyes, it is necessary to take photos, or dilate the eyes.

*Issues such as diabetes, eye tumors, high blood pressure, retinal tears, and glaucoma often have no symptoms associated with them. Through examination, these can often be treated before vision loss or blindness occurs.

If you have a preference, please choose below. If not, the doctor will discuss their recommendation with you.

These photos offer an alternative to dilation of the eyes! They create a permanent record of the retinal/eye health. There is a screening fee of $35.00.

With these drops, your near vision will likely be blurry for 4-6 hours, and you will be light sensitive. Sunglasses are recommended and will be provided when needed. Patients are usually able to drive.

Without dilation or photos, the doctor is only able to see a small portion of the back of the eye. By choosing this, you acknowledge that the eye is not being fully examined.

Signature: Date:

Notice of Privacy Practices Acknowledgement and Consent

View Notice of Privacy Practices

ACKNOWLEDGEMENT and CONSENT

I understand that InVision Eye Care/Camas Optique, (referred to below as "The Practice") will use and disclose health information about me in order to:
  • Make decisions about and plan for my care and treatment;
  • Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment;
  • Determine my eligibility for health plan or insurance coverage, and submit bills, claims, and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
  • Perform various office, administrative and business functions that support my physician's efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.


I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I also understand that I have the right to receive and review a written description of how the Practice will handle health information about me. This written description is known as a "Notice of Privacy Practices" and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of the Practice, and my rights regarding my health information.

I understand that the "Notice of Privacy Practices" may be revised from time to time, and that I am entitled to receive a copy of any revised "Notice of Privacy Practices". I also understand that a copy or a summary of the most current version of the Practice's "Notice of Privacy Practices" in effect will be posted in the reception area.

I understand that I may revoke my authorization at any time by notifying the person/organization providing the information in writing, except to the extent that: action has been taken in reliance on this authorization; or if this authorization is obtained as a condition for obtaining insurance coverage, other laws provide the insurer with the right to contest a claim under the policy.

By signing below, I agree that I have reviewed and understand the information above and that I have reviewed a copy of the "Notice of Privacy Practices."

Patient Signature:Date:
Patient Representative:Date:
Description Of Representative's Authority:

24 Hour Cancellation and "No Show" Fee Policy

Recognizing that everyone's time is valuable and the appointment time is limited, we ask that you provide a 24 hour notice if you are unable to keep your appointment. Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, the Physicians' of Camas Optique reserves the right to charge a fee of $40.00 for each missed (No Show) appointment, which is, absent for compelling reason, and is not cancelled within 24 hour advance notice. "No Show" fees will be billed to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. Multiple "No Shows" in any 12 month period will result in termination from our practice. Thank you for your anticipated cooperation.

By signing below, you acknowledge that you have received this notice and understand this policy.

Signature: Date:

If you are here for a vision exam today...

Vision appointments and plans cover routine eye exams in order to check your eyesight, screen for potential medical conditions or prescribe glasses. Your vision appointment has been scheduled with this in mind. Most plans cover eye exams every 12 or 24 months. Please, remember, it is your responsibility to know if your benefit is now available. If a medical condition is found, we may ask you for your medical insurance information. Depending upon coverage, you may be asked to return for another office visit if:

     - Your managed care plan requires a referral to see a specialist.
     - Today's schedule does not allow for the complete workup of your medical eye condition.
     - Further testing is necessary.

Assignment of Benefits and Release of information

Please keep in mind that it is your responsibility to know whether you have available insurance benefits. If these benefits are not available, payment is required at the time of services. Insurance benefits are quotes given to our office by your insurance company, and are not guaranteed. It is ultimately your responsibility to know and understand your insurance coverage. I authorize Camas Optique to release information needed for insurance claims to my insurance provider. If at the time of service, any additional amount is owed on this or subsequent visits, I agree to cover these expenses. I authorize the release of medical information to my Primary Care Physician for continuity of care when necessary.

Signature: Date: