Online Patient Questionnaire

Patient information

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Billing information

If yes, please provide the billing address information below

Primary Vision Insurance

Primary Medical Insurance

Please choose from the menu options or select the option to type in your own text. Thank you!



Eye History

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Contact Lens Wearers Only


Family Eye History

Does anyone in your family have any of these eye conditions?





Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?

Review Of Systems





Social History

Vision Therapy History


Medical History


List significant illnesses, bad falls, high fevers or chronic illnesses:


Developmental History:


During pregnancy of this child, did any of the following occur:


@birth

My child is:


Skills / Milestones





Has your child undergone any of the following testing / treatment/ therapy?


Visual History


Do you observe or does your child report any of the following?


Strabismus / Amblyopia History

TBI History

What Types Of Professional Care Have You Received or Are Receiving Due To This Injury?


Brain Injury Vision Symptom Survey

Score Each Behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4



If you experience any of the symptoms below, please check if the symptom was present before the injury or only after:




Dry Eye History


Over the past week, which of the following eye symptoms have you experienced?


Reading and Computer Symptom Checklist


CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)


Please answer the following questions about how your eyes feel when reading or doing close work.


NOTE: if the patient is a child, please read the instructions and then each item exactly as written.


Never=0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4


Check All That Apply:



Dizziness And Motion Sensitivity Checklist


Policies, Consent, Submit Data


PATIENT FEES & RESPONSIBILITY



Please note that full payment of co-pays, overages, non-covered items, etc. is required at the time services are rendered. Verification of eligibility and authorization numbers from your insurance company is not a guarantee of payment. The final determination of payment is made when the insurance company receives your claim. Any fee that your insurance does not cover is your responsibility. If insurance reimbursements are not made back to our office within 30 days, then the entire balance becomes your responsibility. Please understand that insurance filing is a courtesy, and you are ultimately responsible for knowing your insurance benefits.

Per the Department of Health & Human Services Evaluation and Management Services Guide, “There are three key components when selecting the appropriate level of E/M service provided: history, examination, and medical decision making. Visits that consist predominantly of counseling and/or coordination of care are an exception to this rule. For these visits, time is the key or controlling factor to qualify for a particular level of E/M services”. So, if you would like to speak to the doctor regarding something, even if an examination is not performed during that time, an office visit will be charged for the doctor’s time as stated in the Evaluation and Management Services Guide from the Department of Health & Human Services.

A refraction may be performed to evaluate if any further visual improvement can be achieved during a medical office visit. However, the refraction is considered a non-covered service by Medicare and medical insurances. The refraction fee is in addition to the fee for medical office visit and is in addition to your co-pay, and must be paid before the patient is seen by the doctor.

If using insurance, I hereby authorize the provider to release any information required to process my insurance claim. I also authorize my insurance benefits to be paid directly to Bright Eye Care & Vision Development. I understand that I am fully responsible for any fees that my insurance will not pay. Regardless of whether I am using insurance, I also understand and agree that no refunds will be given for any product, whether I pick up the product or not, or service because of the personalized nature of healthcare. I also understand and agree that there is no warranty or refund on broken or lost eyewear. I also agree and understand that there are no refunds for services or products. I agree to and understand all that is written in this document, and understand that this document holds true beginning today and for all subsequent visits and transactions in the future.

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What is the major purpose of this visit?:



This will help determine what type of exam you will need. If you are here for a medically related issue - red eye, painful eye, etc… - then you will need an office visit. If you are here to check for the need for glasses, then you will need a yearly eye exam. If you need a contact lens exam, then that would be a different type of exam. Each type of exam requires a different fee. Please direct any questions about fees to the front staff. The doctors will not discuss fees.



Dilation



Dilation during a routine yearly eye exam does not check for eye diseases because those conditions are not routine. If you have a known eye disease or a medical concern involving the eyes, separate diagnostics and medical decision-making will necessitate a medical office visit as opposed to a yearly eye exam with dilation to investigate the disease process or concern. For example, if you are concerned about diabetes in the eye, you will need to schedule a medical office visit with us rather than just receiving a dilation with your yearly eye exam. Once dilated, you will be sensitive to sunlight and will not be able to read clearly for the next four to five hours. A pair of temporary sunglasses will be provided to help reduce sensitivity to light.

I understand & agree with the above statement.

I would like to (please check a box):