Patient Forms

Patient Name

DOB

Address

Phone

Vision Plan

Subscriber

Subscriber DOB

Name

Date of Birth

Primary Care Physician

Preferred Pharmacy

Last Eye Exam

Where?

What brings you to the office today?

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Family History (other than yourself): (please check applicable family members)

Unknown Family History

Glaucoma

Parent

Sibling

Maternal Grandparent

Paternal Grandparent

Macular Degeneration

Parent

Sibling

Maternal Grandparent

Paternal Grandparent

Blindness

Parent

Sibling

Maternal Grandparent

Paternal Grandparent

Other disease, please list.

Others, please list.

Please list General Surgeries

Current Eye Medications

Current Systemic Medications: (supply a list or review printed list)

Social History: (please select all that apply)

Smoking

Current smoker Vape use Former smoker Never smoked Lives with a smoker

Alcohol use

Yes No

Recreational drug use

Yes No

Do you wear glasses? If yes, please check all that apply:

Over the counter readers

Progressive

Bifocal

Distance only

Reading only

Do you have prism in your current prescription to correct double vision?

Contact lens patients please provide:

Brand of contacts

Hours of wear

Cleaning solution

Brands that have not worked in the past

Optomap Ultra-Widefield Imaging Technology

At standard the optical of shop, we pride ourselves in providing our patients with the best possible care. Because of this, our doctors strongly recommend that all patients have an Optomap Retinal Exam. This non-invasive procedure allows your doctor to see a much broader and detailed view of the retina than is possible with conventional methods. When reviewed, the scan becomes a permanent part of your medical file, enabling your doctor to make important comparisons should potential vision threatening conditions show themselves at a future examination. Our doctors believe that the Optomap Retinal Exam is an important part of your comprehensive eye exam and offer it to all patients every year.

This imaging device allows the doctor to detect retinal abnormalities, glaucoma, macular degeneration as well as other health conditions such as diabetes, high blood pressure, cholesterol, tumors, and other life-threatening diseases.

Our Doctors Recommend Optomap for the Following Reasons:

The ability to show you your retinal images today, during your exam
An in-depth view of nearly the entire retina (where diseases can start)
A permanent record for your medical records, which gives your doctor a comparison for diagnosing and tracking retianl eye disease annually

Optomap Retinal Imaging is:

Fast, easy, comfortable, and patient friendly.
Eliminates the need to be dilated (in most cases); New patients will be expected to dilated.

*Please Note: The Optomap Retinal Screening Exam is not covered under your basic health plan, meaning that your are responsible for the charges. Our fee for the retinal screening, measurement and interpretation is $35.00. We will collect this fee along with your co-payment and deductibles at the end of your visit.

Please select one

I elect to have an Optomap Digital Retinal Image of my retina.

I do not want an Optomap Retinal Image; I am willing to be dilated.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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