Patient Registration Online Form Male Female Date of Birth MM slash DD slash YYYY SSNName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork /ExtCell PhoneE-mail address Preferred method of contact Email Text Voicemail Employer/School Occupation/Grade If you are new to our office, please indicate how you found out about our practice When was your last eye exam? When was your last physical exam? Who was the Doctor? PRIMARY INSURANCEName of Policy Holder Medical Vision SSN or Member ID Primary DOB MM slash DD slash YYYY SECONDARY INSURANCE Name of Policy Holder Medical Vision SSN or Member ID Primary DOB MM slash DD slash YYYY REASON FOR VISIT No problems/Regular check-up I would like new glasses I would like contact lenses My distance vision is blurry My near vision is blurry HEALTH INFORMATIONSince certain conditions are hereditary, it is important that we know you and your family’s health history. Only denote blood relatives.yourselfmotherfathergrandmothergrandfatherbrothersisterMultiple SclerosisCancer/TumorsHigh Blood PressureDiabetesKidney/Liver ProblemsHIVHepatitisHigh CholesterolArthritisThyroidAsthma/BronchitisStrokeCataractsGlaucomaFlashesFloatersLazy EyeDry EyesItchingBurningTearingRednessBlurred VisionVisual Field LossRetinal DetachmentDouble VisionColor Vision LossMacular DegenerationOther Explain any eye injury or surgery List all drugs/medications are you takingCondition prescribed for Drug allergies Are you pregnant or nursing? Yes No Do you smoke? Yes No VISUAL NEEDS ASSESSMENTWhat is your primary form of visual correction? Glasses Soft contact lenses Gas permeable contact lenses No correction When was your last change in glasses? What are your current glasses? Single Vision Bifocals Trifocals Progressive (no line) Do you have prescription sunglasses? Yes No Do you have spare glasses? Yes No Do you use a computer? Yes No How much time on average do you spend on a computer daily? CONTACT LENSESDo you currently wear contact lenses? Yes No Have you ever worn contact lenses? Yes No how long ago? What type? Soft Rigid Would you want to wear contact lenses? Yes No Explain when you would rather not wear glasses What type? Daily disposables Two-week disposables Monthly disposables Non-disposable soft lenses Rigid gas permeable Unknown Do you sleep in them? Yes No Rarely Once a week Few nights/week Regularly Naps Max daily hoursOn average, how many hours a day do you wear contacts?What contact solutions do you use? What moisture drops do you use? What would you like to improve about your contact lenses? ULTRA-WIDEFIELD RETINAL IMAGING Optomap Ultra-widefield Retinal Exam is a revolutionary diagnostic tool that allows Dr. Wlodek to view a majority of the retina. The Optomap is a non-dilating camera that captures a digital image of the retina. Retinal imaging is the preferred method for Dr. Wlodek to monitor your eye health. Retinal imaging is recommended yearly. There is a $35 fee to perform this procedureIt is the policy of Optical Effects Vision Center to require: All exam fees to be paid in full on the date of service Payment in full or a 50% deposit before an order can be placed Balance to be paid when the order is dispensed/li> We will do all we can to find out what your vision insurance benefits are and what you are eligible for. We will also submit your claim for you. The information given to us by your insurance company, however, is not a guarantee of payment from them. All orders are final when placed. I understand I am responsible for any charges not covered by my insurance company. I acknowledge that I received a copy of Optical Effects Vision Center Notice of Privacy Practices. Patient/Guardian SignatureSignature required for insurance company billingDate MM slash DD slash YYYY Thank you for choosing Optical Effects Vision Center for your eye care needs
Closed Daily for Lunch 12PM-1PM
Optical Effects Vision Center is conveniently located in a busy shopping complex at the corner of Maryland Parkway and Silverado Ranch Blvd, just across from UFC Fitness.