1Patient Information2Insurance3Eye Health History4Health History5Wellness Retinal Imaging Consent Form Patient InformationFirst Name*Last Name*Birth Date* Month Day Year Sex* M F Email Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneSocial Security NumberEmergency ContactEmergency Contact PhoneRace Alaska Native Asian Black/African American Caucasian/White Native Hawaiian/Pacific Islander Native American Refuse to Specify Ethnicity Hispanic/Latino Non-Hispanic/Latino Unknown Refuse to Specify Patient Status Single Married Divorced Widowed Other Preferred Language (other than English)EmployerOccupationHow did you hear about us? Internet Insurance Listing Advertisement Drive By Social/Work Doctor Family/Friend Referral Who referred you? Insurance InformationWill we be billing insurance for your appointment?* Yes No Insurance CompanyID #Group #Subscriber Name*Subscriber Birth Date* Month Day Year Subscriber SSN #Relationship to patientIs patient covered by other insurance? Yes No Eye Health HistoryDate of last eye examLocation / Doctor name (if not here)Do you wear glasses? No Yes, part time Yes, full time Do you wear contact lenses? Yes No Please list type, hours/day, and the solution you use*Do you have any of the following? Check all that apply. Blurred Vision Eye Injury / Head injury Flashes Headaches/Migraines Loss of Vision Chronic Eye Infections Eye Strain Floaters/Spots Itchy Eyes Poor Night Vision Dry Eyes Fainting/Blackouts Halos Light Sensitivity Watering Eyes Health HistoryPrimary Physician NameDate Last SeenAre you using any medications, either prescription or otherwise? Yes No Please ListVitamins or Supplements?Are you allergic to any medications? Yes No Please ListPlease check to indicate if you have ever had any of the followingIf a blood relative has had any of the following health problems, please list below. Eye Disease (ex: glaucoma, macular degenera-on, re-nal disease, blindness) Eye Condition (ex: strabismus / eye turn, amblyopia / lazy eye, poor color vision) Eye Surgery (ex: cataracts, re-nal detachment, LASIK / PRK, ptyergium, blepharoplasty) Ear/Nose/Throat Condition (ex: vertigo, tinnitus, chronic sinusitis) Cardiovascular Disease (ex: high blood pressure, cholesterol, heart disease, heart attack, stroke) Respiratory Condition (ex: asthma, COPD, emphysema) Musculoskeletal Condition (ex: arthritis, osteoporosis, bone/joint condition, muscle condition) Skin Condition (ex: rosacea, eczema, psoriasis, hives, rashes) Neurological Disorder (ex: headache, migraines, epilepsy, seizures, sleep disorder, paralysis, dementia) Psychiatric Disorder (ex: depression, chemical dependency, anxiety disorder) Endocrine Disorder (ex: thyroid, diabetes, malaise) Blood / Lymph Disorder (ex: AIDS/HIV, anemia, hepatitis) Gastrointestional Disorder (ex: esophageal reflux, IBS, digestive problems) Genito-Urinary Disorder (ex: kidney disease, incontinence) Allergic/Immunological Condition (ex: cancer, lupus, seasonal allergies, autoimmune disorders) Constitutional (weight loss, fever) Other Please ListPlease list any blood relativesPlease list any surgeries you have hadDo you smoke or use tobacco products? No Occasionally 1/2 pack per day 1 pack per day 1+ pack per day Chewing Do you drink alcohol? No Occasionally 1 per day 2 per day 4+ per day Do you use illicit (illegal) drugs? Yes No Type and frequencyDo you engage in regular exercise? Yes No Are you pregnant or breast-feeding? Yes No Hobbies/InterestsPatient First NamePatient Last NameYour E-Signature*Today's Date* MM slash DD slash YYYY Wellness Retinal Imaging Consent FormAs part of your eye exam Dr. Fraser recommends a special diagnostic procedure called Wellness Retinal Imaging. This procedure consists of capturing an image of the back part (retina) of your eye. This is not an x-ray or ultrasound procedure; and nothing will touch your eye. We are simply taking a digital photo. This permanent record is very valuable in assessing the current health of your eye and for safeguarding the health of specific structures of your eye, such as the retina, optic nerve, macula, and blood vessels. It will also serve as an initial point from which to compare, as we follow your health in subsequent years. The fee for this part of the eye exam is $20.00. Depending on your diagnosis, this test will not be covered under your medical insurance or Medicare. Retinal images are also not covered under most vision plans. This office will advise you of your coverage. You may be required to submit a receipt for reimbursement from your insurance provider.Please select* Yes, I want to have retinal photos taken of my eye for documentation No, I do not wish to have retinal photos taken Your E-Signature*Today's Date* MM slash DD slash YYYY Financial PolicyFINANCIAL POLICY Payment is expected at the time services are rendered, unless other arrangements have been made in advance. If you have insurance, as a service to you, we will make an initial attempt to bill your primary insurance carrier and see that they provide payment in a timely manner. Secondary insurance coverage is to be billed as a patient responsibility. Benefits quoted are not a guarantee of payment by the insurance, final determination can only be made when the claim is processed. If your insurance delays or disputes a claim beyond 90 days, you will need to pay your account in full and make arrangements with your insurance for reimbursement. Our office provides standard of care as determined by the American Association of Optometry. Insurance companies may have limitations or exclusions on recommended treatments. It is up to the patient to know their insurance policy and possible limitations or exclusions. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred at this office regardless of insurance. Accounts 90 days old are subject to collection fees plus an $75 processing fee. There will be a service $25 charge on all returned checks. All sales are final. SCHEDULING POLICY Appointment times have been specifically reserved for you and we take every measure to run our schedule on time. If you will be unavoidably late for your appointment, please call us to let us know. If you arrive more than 15 minutes late, we may need to reschedule your appointment. There will be a $50 charge for "no-shows" or missing your appointment without patient cancelation. PRIVACY POLICY and ACKNOWLEDGEMENT A copy of our privacy policies will available by request at any time as mandated by federal law. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notices of Privacy Practices.Patient First Name*Patient Last Name*Your E-Signature*Today's Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.