Optical New Patient

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

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

Confirmation EmailConfirm email

Date of Birth*

Date

Vision Insurance Information

I dont have Vision Insurance

Name of Insurance Company

Policy of Subscriber ID

Please include any Alpha Prefix

Group Number

Policy Holder Name

Policy Holder Date of Birth

Policy Holder Relation to Patient

Policy Holder Last Four of Social Security No.

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.

Our doctors’ current opinions are that Optomap is not a complete
replacement for dilating the pupils. However, during this time of
COVID-19 and to decrease the risk of viral spread, the doctors prefer
that patients utilize this option in lieu of dilation.

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 $33 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

*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

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