Patient Information Form

Welcome to Eyecare of Austin

New Patient Registration Form
This form contains confidential information and is delivered to your doctor through a secure Internet connection. Please answer our screening questions in order to proceed.
Full Name*

First NameMiddle NameLast Name
Gender?*

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
Age*
Phone Number (best number to reach you)*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of your employer
Vision insurance*
Medical insurance*
Reason for Today's Visit*
When was your last eye exam?
Do you wear glasses (check all that apply)*

For distanceFor readingNo, but used to in the pastNeverOther
Do you wear Contact Lenses (check all that apply)*

YesNo, but used to in the pastNeverInterested in tryingOther
If you wear contact lenses please list brand and type if known (ex. Acuvue Oasys, Biofinity Toric, Air Optix Multifocal)
Have you been diagnosed with or ever had any of the following?*

Amblyopia(Lazy eye)AstigmatismCataractDry eyeEye infectionEye InjuryEye patchingEye surgeryEyelid droopMacular degenerationRecurrent eye infectionRetinal detachment/holes/tearsStrabismus (eye turn)Vision therapyNONEOther
Have you recently or are you currently experiencing - Check all that apply*

Blurred Vision at DistanceBlurred vision at nearBurningDischarge or crustingDouble VisionDrooping eyelid(s)DrynessFlashes of light/Floating spotsForeign Body SensationGlare/HalosHeadachesInfection of Eye or LidItchingPain and/or SorenessRednessSandy or Gritty FeelingTired EyesWatery EyesNONEOther
Have you experienced problems with any of the following:*

DiabetesCardiovascularHigh Blood PressureThyroid ConditionCancerGIThyroidNervous systemSkinRespiratoryMusculoskeletalEars/nose/throatPsychiatricBlood/lymphAllergyNONEOther
If yes to any of the above please list condition(s)
Please list ALL medications/ eye drops and over the counter medication or write NONE (List purpose of medication if unsure of name)*
Do you smoke cigarettes? If yes, how much?*
Please list any allergies to medication or write NONE*
Are you pregnant or nursing?*

YesNonot applicable

Family medical history*

	Mother	Father	Brother	Sister	NONE
Diabetes
High blood pressure
Cancer

Family ocular history*

	Mother	Father	Sister	Brother	NONE
Glaucoma
Macular degeneration
Retinal detachment
Cataract

Optomap® Retinal Exam

Eyecare of Austin offers Optomap® Retinal Exam as an integral part of your eye exam today. This non-invasive procedure allows your doctor to see a much broader and more detailed view of the retina than is possible with conventional methods. These conditions may otherwise go undetected using traditional examination techniques and equipment. Simultaneous, non-contact central pole-to-periphery views of up to 82% or 200 degrees of the retina are displayed in one single capture.

Our advanced digital retinal imaging provides:

A digital computerized, ultra wide-field image of your retina without usual dilation.

The ability for you to see what the doctor sees when looking at the back of your eyes.
A permanent record for your medical file; year to year screenings for potential eye disease and tracking of diagnosed eye disease.

Insurance - Your plan may provide you with basic vision coverage, however, it does NOT include advanced disease detection procedures like the Optomap® Retinal Exam.

The fee for this Optomap® Retinal Exam is $39.00
Patient Financial Responsibility Statement
Signature*

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I AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN AND THE AGREEMENT SHALL BE IN FULL FORCE AND EFFECT.
Notice of Privacy Practices
Signature*

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ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that I have received or had available to me the office's Notice of Privacy Practices.
By signing below, I authorize Eyecare of Austin, PLLC to release my glasses and/or contact lens prescriptions along with basic identifying information such as name, date of birth, address, phone number and date of visit to the email address or a fax number I provide.
Signature*

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ACKNOWLEDGEMENT OF CONSENT FOR ELECTRONIC TRANSMISSION
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Welcome to Eyecare of Austin