Name*

First MI Last

Date of Birth*

Mailing Address*

Street Address Address Line 2 City State Zip Code

Home Phone #*

Cell Phone #

E-mail Address*

(used for recall purposes)

If patient is a dependent:

Responsible party

Relationship

How did you hear about us?

(Examples: walk-in, referral, internet search, previous Costco exam, insurance)

Approximate date of last eye exam?

Location of last eye exam?

Main purpose of today’s visit?

Do you currently wear glasses?*

Yes
No

Do you currently wear contact lenses?*

Yes
No

Are you interested in wearing contact lenses?*

Yes
No

Are you interested in Lasik vision correction?*

Yes
No

Ocular Health

Please mark any of the following that apply to you

If other, please specify:

Please list medications you are taking and what they are being taken for:

Medication	Reason

Please list any significant medical conditions not listed above:

Please list any medications that you are allergic to:

Family History

Please mark any of the following that are in your direct bloodline.

Diabetes
Glaucoma
Macular degeneration
Blindness
Other

If other, please specify:

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, and that you have read and understand the exam fee policy sheet. Your signature will also serve as a “signature on file” allowing us to bill your insurance if you are asking us to do so.

Patient/Guardian’s Signature

Date

Optomap Retinal Exam

Dr. Lewis & Associates offers a state‐of‐the‐art digital scanning technology that allows us to view the inside of your eye without the use of dilation drops in most cases. The OPTOMAP allows us to evaluate your retina for problems such as retinal tears, retinal detachments, retinal tumors, macular degeneration, hypertension, and diabetic retinopathy. This scanning system is completely safe for kids and adults and does not emit radiation like an X-ray.

Dilated Exam vs. Optomap Exam

Dilated Exam
1. Blurred near vision for 4 – 6 hours
2. Light sensitivity for 4 –6 hours
3. Longer office visit to wait for drops
4. No permanent record of retina
5. Only the doctor can see the retina

Optomap Exam
1. No blurred vision
2. No light sensitivity
3. Images can be captured in 0.25 of a second
4. Permanent record of retina for future comparison
5. You can see your retina!

We recommend that ALL patients have a thorough examination of their retina during their routine eye exam. Without the Optomap or the dilated examination, the doctor cannot fully assess the health of the back of your eyes. There is an additional fee of $25 for the Optomap. In most cases, this procedure is not covered by insurance.

I elect to have an Optomap ($25) and understand it is not required but recommended by Dr. Lewis.
I prefer a dilated exam of my retina and I have been informed of the side effects listed above.
I do not wish to have either the Optomap or dilation performed, and understand the risks involved.
I wish to speak with the doctor first before making a final decision.

Patient Signature

Date