intake Name(Required) First Last Date of Birth.(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mailing Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone(Required)E-mail Address (used for recall purposes)Responsible party & relationship if patient is a dependent How did you hear about us? (Examples: walk-in, referral, internet search, previous Costco exam, insurance) Do you have a preference as to which doctor you see? (Choose no preference if you want the most appointment scheduling options)(Required)No preferenceDr. Scott LewisDr. Jessica WalkDr. Evelyn HuApproximate date of last eye exam?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Location of last eye exam (write "this office" if last seen here or write the name of the clinic you were last seen at if seen elsewhere)?(Required) Main purpose of today’s visit?(Required) Do you currently wear glasses?(Required) Do you currently wear contact lenses or have you worn contact lenses in the past?(Required) Are you interested in wearing contact lenses and would be a new wearer that would need a longer office visit for training on how to insert and remove contact lenses? (Write "not interested" if you are not interested in contact lenses or "currently wear" if you currently wear contact lenses)(Required) Have you had or are you interested in Lasik vision correction?(Required) Ocular Health – please check any of the following that apply to you or click “none” if none apply(Required) Floaters Flashes Dryness Redness Pain Itching Eye strain Double Vision Lasik Injury Cataract Glaucoma Macular Degeneration None Other Other Please list medications you are taking and what they are being taken for. If you are not taking any medications, please type "None"(Required)Please list any significant medical conditions not listed above. If you have none, please type "None"(Required)Please list any medications that you are allergic to. If you have no allergies, please type "None"(Required) Family History – please check any of the following that are in your direct bloodline(Required) Diabetes Glaucoma Macular degeneration Blindness None Other Other Federal law requires you be made aware of your privacy rights regarding personal medical information. By signing you acknowledge that you have been offered a copy of the federal HIPAA privacy policies.OptomapOptomap Retinal Imaging Dr. Lewis Eyecare offers Optomap retinal imaging technology that allows us to view the inside of your eye without the use of dilation drops in most cases.The Optomap is quick, painless, and makes detecting eye disease easier.Why should I have an Optomap during my eye exam instead of being dilated? No eyedrops are needed to see your retina in most casesNo blurred vision or light sensitivity after having an OptomapNo radiation like an X-ray and is completely safe for kids and adultsShorter amount of time needed for your appointment so you can get on with your busy dayRetinal health problems sometimes have no symptoms yet can lead to vision lossSystemic health problems such as high blood pressure and diabetes can be detected Permanent image of your retina for future comparison, making eye health changes easier to detectYou can see the images of your retina leading to better understanding of your own eye health Dilated view (circles) show only partial views of the retina similar to shining a flashlight into a dark roomOptomap shows full view of retina in one image similar to turning the lights on in a dark roomWe recommend that ALL patients have a thorough examination of their retina during every routine eye exam. Dr. Lewis feels that the Optomap is the best way to fully assess your eye health. There is an additional fee of only $25 for the Optomap. In most cases, the Optomap is not covered by insurance. (Required) I elect to have an Optomap image ($25) which has no side effects, and understand it is not required but recommended by our doctors as the best way to assess my eye health. I prefer a dilated exam of my retina where drops will be put in my eyes requiring a longer office visit (20 minutes for the drops to take effect), and the drops will cause blurry and light sensitive vision for 4-6 hours. I do not wish to have either the Optomap image or dilation performed, and understand that I am limiting my doctor’s ability to diagnose eye diseases that could lead to vision loss. Questions? A short video explaining the Optomap can be found at:https://www.youtube.com/watch?v=QxQdQwGI3kEPatient/Guardian’s Signature(Required)Date(Required) MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
