Fill - Free fillable Please let the doctor know what issues you PDF form

Last, First, M.______________________________________________________________________M/F D.O.B.___/___/_______

Preferred Phone #: (____)______-__________Email: _____________________________________@_______________________

Please let the doctor know what issues you are having with your eyes or vision today? Please briefly explain.

(This section must be filled out. The following examples are medical issues: floaters, flashes, dry eye, glaucoma, diabetes, macular or

retinal issues, red eye, blepharitis, conjunctivitis, discomfort, foreign body, headaches, high risk medication exams, cataracts, bleeding,

binocular vision issues, tracking issues, amblyopia, strabismus)

____________________________________________________________________________________________________________

Are you here for your annual exam? □Yes □ No

Are you interested in new glasses, frames, or lenses? □Yes □ No □Maybe

Do you wear contact lenses? □ Yes □ No

If you do not currently wear contact lenses, are you interested in contact lenses? □Yes □ No □Maybe

Height ____Ft______inches Weight____________lbs Primary care physician __________________________

Are you diabetic? □Yes □No Circle: Type 1 2 HbA1c: _____ Fasting Blood Sugar: _____ Treating Dr.: ___________

Are you on a high risk medication (Hydroxychloroquine, Plaquenil, Tamoxifen) □Yes □No

Treating Dr.: ____________________

Do you have dry eyes? □ Yes □No

Would you like dry eye testing? □ Yes □No

Would you like glaucoma early detection screening today (age 50+) $45.50 (out of pocket) □ Yes □No

Would you like more information on macular degeneration EARLY detection screening? □Yes □No

(age 50+) $85 (billable to medical insurance and may require a separate visit)

Would you like more information on night vision testing? □Yes □No

(age 50+) $85 (billable to medical insurance and may require a separate visit)

Are you here for a visual therapy evaluation? □Yes □No

OPTOMAP

Your insurance is designed to cover a basic or wellness eye exam. It does not cover advanced screening tools such as the

Optomap. The doctors would like for all their patients to have an Optomap screening annually to aid in the detection of

disease in the back of the eye. Screenings are $45.50. In some cases, your doctor is required to dilate the eye(s) as well,

including, but not limited to diabetes, macular degeneration, flashes, floaters, ocular trauma, and post surgery. If a medical

diagnosis is found on the Optomap screening, you may elect to have it sent to your medical insurance for possible coverage.

Many insurances cover retinal photography, but I understand that if my medical insurance does not, I will be responsible for

the charges. Circle one: Optomap Dilation (You must make a selection) INITIAL__________

RELEASE OF INFORMATION

I give my permission for Premier Eyecare, Doctors of Optometry. To release/dispense my medical records, insurance

information, billing statements, prescriptions, contact lens, and/or eyeglasses to the following person(s) listed below. I

understand that it is my responsibility to follow-up with the person(s) listed below to receive the reports or item. I understand

the provider is not responsible for loss, stolen, or misuse of information or items released to the person(s) listed below. I

understand if my records are subpoenaed by law, that the provider must furnish medical reports and billing. You may also

request a restriction on disclosure of protected health information to a health plan for purpose of payment or health care

operations if you paid for the services, at the time of the services, out of your own pocket in full. This does not apply to

services covered by insurance. Please release to: (This includes spouses, parents, schools, or other health care professionals.)

(1)___________________________________________________ Relationship _________________________

(2)___________________________________________________Relationship__________________________

Signature_____________________________________________________________________Date__________________

Print_________________________________________________________Relationship (if not self)___________________

Patient(self)/Legal Guardian

CREDIT CARD AUTHORIZATION FORM

authorize Premier Eyecare, Angela Tsai, O.D. and Associates, P.C. to charge my credit card stored by

Professional Merchants, Inc. for agreed upon services/purchases. I understand that my information will be saved to

file for, including but not limited to, future transactions, recurring payments, payments used to fulfill payment

agreements, moneys owed after insurance is applied, credits or debts on my account. I understand I may cancel

this authorization by written notice no later than 24 hours before a payment or credit is applied. This

authorization will remain in effect until further notice.

Credit Card Type:

☐

MasterCard

☐

VISA

☐

Discover

☐

AMEX

Cardholder Name (as shown on card) ____________________________________________

Card Number: _____________________________________ Exp Date (mm/yy):_________________ Zip:__________

Cardholder Signature_________________________________________________________Date_______________

COVID-19 QUESTIONNAIRE

Please answer the questions completely. If you are scheduled for a comprehensive examination and have any of these

symptoms within the past 14 days, please let us know as soon as possible. We will be happy to accommodate you and

reschedule your appointment. Appointments that must be rescheduled or cancelled within 24 hours, will be assessed the no

show or cancellation fee of $35 or $50 during peak seasons of July 15-August 15 and December 26-31. If you have had

COVID-19, and requesting a comprehensive examination, you must present with proof of your negative COVID-19 test.

Emergency cases will be handled as each individual case arises.

Check each box: (You must make a selection)

Have you had COVID-19? □Yes □ No If you have, when did you have it? Date__/___/_____ - ___/___/_____

If you have, have you had a negative test performed in the past 2 weeks? □Yes □ No

I have been out of Virginia in the past 14 days □Yes □ No

I have traveled out of the country in the past 14 days □Yes □ No

I have

Fever □Yes □ No

Chills □Yes □ No

Cough □Yes □ No

Shortness of breath or difficulty breathing □Yes □ No

Fatigue (different than normal) □Yes □ No

Muscle or body aches □Yes □ No

New loss of taste or smell □Yes □ No

Sore throat □Yes □ No

Congestion or runny nose □Yes □ No

Nausea or vomiting □Yes □ No

Diarrhea □Yes □ No

COVID-19 PROTOCOL

Please call 540-373-3021 to schedule your appointment or for glasses/contact lens-related adjustments, drop-offs, or pick-

ups. Please read the following as this applies to all patients.

All patients will be screened over the phone and upon arrival for COVID-19-related questions. You will be required to wear a

mask and have your temperature taken upon entrance. If you do not have a clean mask to wear upon arrival, we will provide

one for you. No gloves are permitted in the facility except by our doctors and healthcare team. We ask all visitors to adhere to

the social distancing requirements of 6 feet apart and will permit no more than 10 people in our optical retail space at a time.

All patients will be required to fill out check-in forms ahead of time to limit the amount of exposure time in the office. All forms

of payments are acceptable and expected at time of service, however, we are no longer accepting checks. Only the patient is

allowed in the facility unless the patient is a minor or requires additional assistance by a caretaker or family member.

Patients requiring contact lens supply pick-ups, or optical adjustments, drop-offs, and pick-ups should call 540-373-3021

option 3 and remain in their car. We will have a team member out as quickly as possible to assist you.

We are happy to have our patients back! Thank you for supporting us and shopping local and supporting small business and

practices.

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