EST Intake Form

Lake Stevens Vision Clinic Intake Form (Returning patient)
COVID-19 SCREENING
Are you experiencing any COVID-19 symptoms (cough, fever, chills, muscle pain, headache, sore throat, new loss of taste or smell):*

YesNo
Have you been in close contact with a confirmed COVID-19 case?*

YesNo
Our office safety protocols require upon entry:
- wearing a face mask
- temperature being taken
- washing / sanitizing hands
- only the patient (and one guardian if necessary) allowed in the office

PATIENT INFORMATION
Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Date
Gender*

MaleFemaleOther
Guardian Name (if applicable)*

First NameLast Name
Social Security Number
This form is secure and HIPAA compliant
Occupation
To understand your visual needs.
Hobbies
To understand your visual needs.
Did your address, phone, or email change*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
We do not spam or share your info.
Home Phone
We do not spam or share your info.
Email
We do not spam or share your info.
Today

MonthDayYear
Date
Age

OPTOMAP RETINAL SCREENING
Our doctors highly recommend the Optomap Retinal Screening to all of their patients for the following reasons:
- It is a non-invasive technique to examine the health of your eye, without the side effects of drops or blurry vision.
- It provides a high resolution picture to compare to in the future.
- It allows for the detection of eye disease sooner than a dilation.
- The Optomap Retinal Screening contributes to our standard of care and improves patient education and satisfaction. There is a nominal copay of $39 for this procedure.
I have read this and understand that a wide field view of the retina is an important part of a comprehensive eye exam.

UPDATE: Dilation requires close face-to-face contact, Optomap screening is especially recommended during these times.
Please choose an option*

I would like to have the Optomap screening.I prefer dilation which has side-effects of blurred vision and light sensitivity.

LIFETIME AUTHORIZATION
I request that payment of all medical benefits to be made on my behalf to Lake Stevens Vision Clinic, Inc. for all services and materials furnished to me by the Physicians at Lake Stevens Vision Clinic, Inc.

I fully understand that I am obligated to pay any portion of the office fees that are not covered by my insurance company, including deductibles, co-pays or non-covered services.

I fully understand that information obtained from my insurance carrier on my behalf, relating to medical or vision care benefits, by the staff at Lake Stevens Vision Clinic, Inc. is not a guarantee of payment or a guarantee of actual benefits to be paid or allowed by my insurance carrier.

If, after 60 days of the initial insurance billing, all account balances owed by myself, any of my dependents, or any insurance carrier to the Lake Stevens Vision Clinic, Inc. have not been paid in full, for whatever reason, I agree to pay those past due amounts in full.
ACKOWLEDGEMENT OF NOTICE OF PRIVACY PRACTIES
I have seen a copy of the HIPAA Notice of Privacy Practices from Lake Stevens Vision Clinic. I am aware a copy can be provided by request, or viewed online at http://lsvc.com/forms.
RELEASE OF RECORDS & EMERGENCY CONTACT
The listed individuals are authorized to receive my protected health information. I am aware I can revoke this at any time, but must do so in writing.*
Include relationship
Emergency contact*
Include relationship
Phone Number*
By signing and pressing submit, I acknowledge that I have read the entirety of this form and answered to the best of my knowledge.
Name*
If patient is a minor, guardian name here.
Date

MonthDayYear
Date
Signature

Clear
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Lake Stevens Vision Clinic Intake Form (Returning patient)

COVID-19 SCREENING

PATIENT INFORMATION

BILLING INFORMATION

HEALTH HISTORY

OPTOMAP RETINAL SCREENING

LIFETIME AUTHORIZATION

ACKOWLEDGEMENT OF NOTICE OF PRIVACY PRACTIES

RELEASE OF RECORDS & EMERGENCY CONTACT