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
I
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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