ULTRA VISION FAMILY EYE CARE

EYE EXAM ESTABLISHED PATIENT INTAKE

Name*

First Last

Date of Birth*

Contact Information*

Has your contact information changed within the past two years?

Yes
No, my contact address, phone number and/or email have not changed.

Address

Street Address Address Line 2 City State ZIP Code

Daytime Phone

Please provide email address:*

Yes, I will
No, I decline

Email Address

Health History

Ocular*

Since your last visit, have there been any major changes pertaining to eye disease, injury, surgeries or any other abnormal conditions for yourself or your family?

Yes
No, there have not been any major changes pertaining to eye disease, injury, surgeries or any other abnormal conditions for myself or my family

Please describe:*

Medical*

Since your last visit, have there been any major changes pertaining to medical illness, injury, disease, surgeries or other abnormal conditions for yourself or your family?

Yes
No, there have not been any major changes pertaining to medical illness, injury, disease, surgeries or other abnormal conditions for myself or my family

Please describe:*

Medications (ALL)*

Drug Allergies (ALL)*

DILATION | VISUAL FIELD | FUNDUS PHOTOGRAPHY TESTINGS

My choices below will indicate my request or denial for each assessment.

Dilation (Included in Eye Exam)*

Dilation drops are used to enlarge the pupil (central, black spot of the eye) to allow a more thorough view of the retina (back of the eye). This allows the doctor to see any signs of diseases (such as cataracts, glaucoma, retina diseases, etc) that may not be detected during a routine eye exam. The side effects include blurred near and intermediate vision (allowing you to see up close) with light sensitivity for approximately 4-6 hours. Dilation is strongly recommended for patients with a history of glaucoma, cataracts, diabetes, high blood pressure, or other problems that may affect the eye. There is no additional charge. Fundus photography can be performed instead of the dilation and/or visual field screening, for an additional fee.

Yes, I would like the dilation performed and am aware of the side effects caused by the dilation.
No, I understand the importance of the dilated examination, but I decline to have it performed at this time. I release Dr. Tam Ha, O.D., and associates from any liability related to the failure to treat or diagnose any eye conditions due to the lack of diagnostic information that could have been detected by this test.
Maybe, I'd like more information about this test.

Fundus Photography - additional $39 fee*

A digital camera is used to capture a permanent image of the retina (back of the eye). Serving the similar purpose as the dilation, the fundus photo can help the doctor find diseases like glaucoma, macular degeneration, diabetes, and high blood pressure that may not be detected during a routine eye exam. This provides the doctor and yourself a visual image of your retina. Unlike the dilation, no side effects will occur. The fundus photo is strongly recommended for patients with a history of glaucoma, cataracts, diabetes, high blood pressure, or other problems that may affect the eye. The test will cost an additional $39.00 and will not be covered by any insurance.

Yes, I would like the fundus photo performed and have no history of seizures.
No, I understand the importance of the fundus photo, but I decline to have it performed at this time. I release Dr. Tam Ha, O.D., and associates from any liability related to the failure to treat or diagnose any eye conditions due to the lack of diagnostic information that could have been detected by this test.
Maybe, I'd like more information about this test.

Visual Field Screening - additional $20 fee*

A highly computerized instrument is used to provide an assessment of your central and peripheral (side) vision. A visual fields test can help with early detection of eye diseases that can lead to blindness, including glaucoma, brain tumors, and optic nerve head diseases. The test will cost an additional $20.00 and will not be covered by the insurance.

Yes, I would like the visual fields test perform.
No, I understand the importance of the visual fields test, but I decline to have it performed at this time. I release Dr. Tam Ha, O.D., and associates from any liability related to the failure to treat or diagnose any eye conditions due to the lack of diagnostic information that could have been detected by this test.
Maybe, I'd like more information about this test.

CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

Health Information Protection*

I have read and agree to the Privacy Policy

I have received and read the office’s HIPAA policy above. A copy of the policy may be provided upon request.

ALL FEES ARE NON-REFUNDABLE AND MUST BE RENDERED AT TIME OF SERVICE

Patient Financial Responsibility*

I have read and agree to the Financial Policy

I have read the office’s financial policy above. A copy of the policy may be provided upon request. I guarantee payment of all charges incurred for the account of the above patient.

Parent or Responsible Party

First Last

Signature*

Date*