Patient Registration Online Form MaleFemaleDate of Birth Date Format: 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/SchoolOccupation/GradeIf you are new to our office, please indicate how you found out about our practiceWhen was your last eye exam?When was your last physical exam?Who was the Doctor?PRIMARY INSURANCEName of Policy HolderMedicalVisionSSN or Member IDPrimary DOB Date Format: MM slash DD slash YYYY SECONDARY INSURANCE Name of Policy HolderMedicalVisionSSN or Member IDPrimary DOB Date Format: MM slash DD slash YYYY REASON FOR VISITNo problems/Regular check-upI would like new glassesI would like contact lensesMy distance vision is blurryMy near vision is blurryHEALTH 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 DegenerationOtherExplain any eye injury or surgeryList all drugs/medications are you takingCondition prescribed for Drug allergiesAre you pregnant or nursing?YesNoDo you smoke?YesNoVISUAL NEEDS ASSESSMENTWhat is your primary form of visual correction?GlassesSoft contact lensesGas permeable contact lensesNo correctionWhen was your last change in glasses?What are your current glasses?Single VisionBifocalsTrifocalsProgressive (no line)Do you have prescription sunglasses?YesNoDo you have spare glasses?YesNoDo you use a computer?YesNoHow much time on average do you spend on a computer daily?CONTACT LENSESDo you currently wear contact lenses?YesNoHave you ever worn contact lenses?YesNohow long ago?What type? Soft Rigid Would you want to wear contact lenses?YesNoExplain when you would rather not wear glassesWhat type?Daily disposablesTwo-week disposablesMonthly disposablesNon-disposable soft lensesRigid gas permeableUnknownDo you sleep in them?YesNoRarelyOnce a weekFew nights/weekRegularlyNapsMax 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 Date Format: MM slash DD slash YYYY Thank you for choosing Optical Effects Vision Center for your eye care needs