Male
Female

Date of Birth

SSN

Name

Prefix First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Work /Ext

Cell Phone

E-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 INSURANCE

Name of Policy Holder

Medical

Vision

SSN or Member ID

Primary DOB

SECONDARY INSURANCE

Name of Policy Holder

Medical

Vision

SSN or Member ID

Primary DOB

REASON FOR VISIT

HEALTH INFORMATION

Since certain conditions are hereditary, it is important that we know you and your family’s health history. Only denote blood relatives.

	yourself	mother	father	grandmother	grandfather	brother	sister
Multiple Sclerosis
Cancer/Tumors
High Blood Pressure
Diabetes
Kidney/Liver Problems
HIV
Hepatitis
High Cholesterol
Arthritis
Thyroid
Asthma/Bronchitis
Stroke
Cataracts
Glaucoma
Flashes
Floaters
Lazy Eye
Dry Eyes
Itching
Burning
Tearing
Redness
Blurred Vision
Visual Field Loss
Retinal Detachment
Double Vision
Color Vision Loss
Macular Degeneration

Other

Explain any eye injury or surgery

List all drugs/medications are you taking	Condition prescribed for

Drug allergies

Are you pregnant or nursing?

Yes
No

Do you smoke?

Yes
No

VISUAL NEEDS ASSESSMENT

What 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 LENSES

Do 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?

Do you sleep in them?

Yes
No

Max daily hours

On 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 procedure

It 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 Signature

Signature required for insurance company billing

Date

Thank you for choosing Optical Effects Vision Center for your eye care needs

Patient Registration Online Form

PRIMARY INSURANCE

SECONDARY INSURANCE

HEALTH INFORMATION

VISUAL NEEDS ASSESSMENT

CONTACT LENSES

Hours

Patient Registration