Returning Patient Form

Returning Patient

If we have seen you in the last 3 years (2020 or later) please continue to fill out these forms. **If it's been longer than 3 years (2021 or earlier) please go to "New Patient Forms" to fill those out instead.**
The information you enter on this page is submitted to a secure site and will be kept completely confidential.
Patient Name*

PrefixFirst NameMiddle NameLast NameSuffix
Nickname (Name Patient Uses)
Preferred Name
Date of Birth*

MonthDayYear
Date
Your Name
If Not the Patient
Relationship To Patient
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Email*

Confirmation EmailConfirm email
Preferred Primary Method of Contact*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Four of Social Security No. of the Patient
Sex*
Gender
Employer (if any)
What is the main reason for your visit?
Vision Insurance Information

*This information will help us verify coverage for your annual eye exam, eyewear, or contact lenses*
I dont have Vision Insurance
Name of Insurance Company
Policy or Subscriber ID
Please include any Alpha Prefix
Group Number
Policy Holder Name
Policy Holder Date of Birth

MonthDayYear
Policy Holder Relation to Patient
Policy Holder Last Four of Social Security No.
Medical Insurance Information

*This information may be needed in the event there is a medical finding during your exam, such as diabetes, glaucoma, macular degeneration, eye infection, etc*
I dont have Medical InsuranceSame Information as Above
Name of Insurance Company
Policy or Subscriber ID
Please include any Alpha Prefix
Group Number
Policy Holder Name
Policy Holder Date of Birth

MonthDayYear
Policy Holder Relation to Patient
Policy Holder Last Four of Social Security No.
For Insurance purposes Only
Upload Insurance Card Image

Browse Files
Please upload an image of the front and back of your insurance card Cancelof
Health History
Approximate date of your last Primary Care Medical Physician visit
Medical Clinic or Doctor's Name
Review of Systems: Please indicate if you are CURRENTLY experiencing any of the following:
General:

Appetite changeFatigueFeverWeight lossNONE
Cardiovascular:

Chest painPalpitationsNONE
Ears/Nose/Throat:

CongestionEar PainNONE
Respiratory:

ApneaShortness of breathNONE
GI:

NauseaVomittingNONE
Genitourinary:

Genital soresNONE
Musculoskeletal:

Joint painBack painMuscle painNONE
Skin:

Color changeRashNONE
Neurologic:

DizzinessHeadachesNumbnessSeizuresNONE
Endocrine:

Excessive thirstExcessive urinationNONE
Psychiatric:

Nervous/AnxietyNONE
Heme/lymphatic:

Enlarged lymph nodesBruise/bleed easilyNONE

Past Medical History: Have you personally been diagnosed with any of the following?

	Check all that apply
Diabetes
High blood pressure
Heart disease
High cholesterol
Sleep apnea
Lung disease
Thyroid disease
Parkinson's
Crohn's disease
Stroke
Vertigo
Asthma
Chronic lung disease
Arthritis
Rosacea
Migraines
Seizures
Concussions
Multiple sclerosis
Allergies

	Check all that apply	Specify:
Hepatitis, type (please specify):
Cancer, type (please specify):

Please list any medications currently being taken:
Please list any known allergies to medications:
Optomap Digital Imaging

Optomap is a non-dilated technology that uses a safe scanning laser to
create an image of the inside of the eye. This technology allows us to
document the internal structures of the eye and detect over 100 different
eye diseases such as retinal detachments, diabetic retinopathy, glaucoma,
macular degeneration, and retinal changes due to high blood pressure and
cholesterol.

Dr. Cole and Dr. Dodd strongly recommend images be taken each year on
all patients, no matter the age, to monitor for any changes. Once the
image is taken, it will be reviewed with you by the doctor in the examination
room.

Click here http://optomap.com/en-US/ for more in-depth information about Optomap.

The procedure is quick and simple! It is not covered by most insurance
companies, as they do not cover screenings. We offer the digital imaging
for $35 on the day of your examination.

Optomap Consent*

	Please Check Selection
Yes - I would like to have Optos performed
Not yet - I have more questions
Not at this time

Consent For Dilation *If recommended by doctor*

Many Diseases such as diabetes, hypertension, glaucoma and tumors of the eye, as well as tears and holes in the retina, can be detected with dilation. Dilation requires placing drops in the eyes to enlarge the pupil which allows a thorough examination of the inside of the eye for these and other problems. The side effects can be blurred vision and light sensitivity for about 2-4 hours. There is no additional charge for this procedure.

Dilation*

	Please Initial Selection	Relationship (if not patient)
Yes - I consent to having dilation performed today
No - I have more questions
Not at this time

HIPAA Privacy Consent

To Our Patients:

Federal law requires that we provide you with a copy of our Privacy Notice.

The Privacy Notice explains how we may use and disclose health information about you. We ask that you sign this form for our records so that we may document your receipt of the Notice.

If you have questions about the Privacy Notice, please feel free to direct these to our Privacy Officer at any time. The name and contact number of the Privacy Officer is listed on your copy of the Privacy Notice.

This HIPAA Notice was provided to:*

	Type Name	Date Signed
Patient (self)
Parent/Guardian to minor
Guardian/POA to adult dependent
Other

Signature for HIPAA*

Clear
*No signature will communicate Decline for Consent
Consent to Disclose Information

We understand that there may come a time where a family member, friend, or other, will need to speak with us on your behalf. This may include, but is not limited to, appointment details, financial information, personal health information, etc. Please list the information of any person that may contact us on your behalf, as consent for us to speak with them. You may also notate Declined Access for certain individuals.

*A blank form will indicate that you have chosen to Decline Consent for Release of Information.

Consent for Individuals *if more than 5, please contact our office directly, after submission

	Name	Relationship	Phone #	Access
Individual 1
Individual 2
Individual 3
Individual 4
Individual 5

Payment Information

Professional fees are due upon completion of services. Although we do bill most insurances, please be advised that payment is still your responsibility. For your convenience, we accept Visa, Mastercard, Discover, personal check and cash. Please note that all returned checks are subject to a $40 charge.
I acknowledge the Payment Information Disclaimer*
Type Name
Should be Empty: