PATIENT FORM - DECATURPatient InformationAre you a...* New Patient Established Patient Last Name* First Name* Gender* Male Female Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Has your phone number changed?* Yes No Home PhoneWork PhoneCell PhoneHas your address changed?* Yes No Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Employer* Occupation* Referred By Insurance InformationMedical Insurance Name* Group # ID #* Insured DOB*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient SSN* Primary Insured Name* Primary Insured SSN* Vision Insurance Name* Medical and Ocular HistoryReason for today's exam?* Are you planning on purchasing new eye glasses today?* Yes No Are you planning on purchasing contacts today?* Yes No Age of present glasses Age of Sunglasses Date of Last Eye Exam Dr? Previous Patient?* Yes No Patient/Family Medical HistoryDiabetes* Self Relative None High Blood Pressure* Self Relative None Thyroid Problems* Self Relative None Heart Disease* Self Relative None Asthma* Self Relative None Cancer* Self Relative None HIV* Self Relative None Glaucoma* Self Relative None Cataracts* Self Relative None Retinal Disease* Self Relative None Eye Surgery* Self Relative None Eye Injury* Self Relative None High Cholesterol* Self Relative None Other Lifestyle QuestionsWork at a computer?* Yes No How many hours a day?* Think will benefit from thinner/lighter lenses?* Yes No Spend time outdoors?* Yes No How many hours a day?* Have RX Sun Wear?* Yes No Prefer not to wear glasses at certain times?* Yes No Do you suffer from Dry Eye?* Yes No Currently have multiple RX glasses?* Yes No Have family members in need of eye care?* Yes No Have small children?* Yes No Do you wish to wear glasses all the time?* Yes No Do you use multiple computers at work or home?* Yes No Are you a... Smoker Former Smoker Not a current or former smoker Brand of Current Contact Lens (if contact wearer) Please explain any positive medical findingsEye drops currently taking (OTC or RX) Medications (OTC and/or RX) Do you have any allergies?* Yes No What medications or treatment are you currently on? Are you allergic to any medications?* Yes No List medications allergic to PAYMENT POLICY FOR SERVICES AND MATERIALS If you are using insurance coverage for today’s visit, this is a contract between you and your insurance company. We will submit whatever we can to assist the process but if Eyeworks is not reimbursed in full, or paid by your insurance company, the balance is your responsibility. If there is any question of coverage, you may be required to pay at time of visit or post visit. Payment for all services are due at time services are rendered. All sales on services and materials are FINAL. Deposits not paid in full or materials left for more than 120 days after order will be forfeited.MEDICARE PATIENTS ONLY: Medicare pays 80% of the allowed fee and the patient is responsible for the other 20% of U&C of exam fee and any copay. Medicare patients are also responsible for the annual Medicare deductible and all non-covered services (including refraction fee).I understand and agree to Eyeworks Policies:Signature*Date Wellness exam vs. Medical eye examIf you have a medical eye issue, it will most likely need to be treated before the wellness examination (Comprehensive Vision Exam) can be performed. YOUR VISION INSURANCE WILL NOT COVER THAT MEDICAL EYE EXAMINATION. Wellness (Vision) exams are strictly to check the overall health of your eye and provide you with an RX for glasses. Medical Exams include but are not limited to corneal issues, pink eye, dry eye, keratitis, stye, chelasium, etc. If you are treated medically, we will need to perform that treatment FIRST and you will need to return for your wellness exam on another date. THIS IS MANDATED BY INSURANCE COMPANIES. In the event that our office is able to file through your medical insurance, you will be responsible for specialist fee dictated by your medical insurance company. If our office is out of network, you do not have medical insurance, you have not met your deductible or other reasons, you will be responsible for a fee of $150-$250, (depending on complexity) at time of appointment when services are rendered. This is something that can be applied to your outstanding deductible. We are happy to provide you with a detailed statement so you can submit to your medical insurance company for any reimbursements or so they can add to your unsatisfied deductible. You will be scheduled for your vision wellness visit when your medical condition has subsided and we will then able to file for your that exam with your vision insurances (you will pay any and all co-pays associated at that time.) Medical Follow-ups follow the guidelines of your medical insurance co-pays and guidelines of your medical insurance company or of the guidelines and policy of Eyeworks. I understand Eyeworks’ policies regarding Wellness Vision vs. Medical listed above and agree to pay.Patient Name* Patient Signature*Date Pretest ProcessAUTOREFRACTOR Autorefractor offers a starting point to begin your eye exam. It is not an exact measurement of prescription but a valuable tool to determine estimated prescriptions. The doctor will exact this RX during your exam. TONOMETRY Air puff to check eye pressure (some call it the “glaucoma test”) OPTOS IMAGING / DILATION We are excited to introduce Optomap, our newest premium standard of care, a requirement for all patients. Optomap image capture reveals greater than 82% of the back of your eye. It can detect vision threatening diseases including but not limited to diabetes, glaucoma, cancer, retinal tears and cardiovascular issues that may be missed with dilation. THERE ARE ZERO SIDE EFFECTS OR LIGHT SENSITIVITY WITH OPTOMAP IMAGING NOR ANY DISCOMFORT AND YOU WILL USUALLY NOT NEED TO BE DILATED AFTER THE OPTOMAP IMAGE IS CAPTURED. Optomap is prescribed annually with an insurance copay of $55. Eyeworks honors this same copay if you do not have vision insurance. Your doctor will go over the results of your Optomap with you as view your images together during your exam and you may request images be emailed. VISUAL FIELD TEST The visual field test can help detect early signs of ocular diseases – including but not limited to glaucoma and macular degeneration - that damage vision gradually. Some people with will not even notice any problems with their vision, but the visual field test will show that peripheral vision is being lost. These diseases untreated or undetected, can lead to blindness. A visual field test can also help the doctor find out more about the part of the nervous system that allows us to see. The visual part of the nervous system includes the retina (the "film" in the camera-like eye), the optic nerve (the "wire" that carries images from the retina to the brain), and the brain itself. Problems with any part of this system can change the visual field. There are well-known patterns in the test results that help doctors recognize certain types of injury or disease. By repeating more visual field tests at regular intervals, doctors can also tell whether the patient is getting better or worse.Would you like to have a visual field test?* I would like to have a visual field test performed. Copay is $25.00. I decline a visual field test today. **Patients who receive Visual Field Test will receive a $10 discount on the two at a combined copay of $70 (save $10) AND a coupon for $15 OFF frame with the purchase of RX lenses to be used day of examination (not to be combined with insurance or other promos). I agree to my pretest examinations. Patient Name* Patient Signature*Date COVID-19 Procedural ConsentOur top priority is the well-being of our patients and their families, thus, Eyeworks is taking every precaution to combat exposure and spread COVID-19. We have instituted the following policies to ensure that everyone is staying safe and healthy. We ask that you read, sign, and abide by our new regulations. Patients are required to schedule exam and glasses purchase appointments. Staff will keep doors locked to manage limited entry to practice. In an effort to minimize the amount of people in the office at the same time, please call when you arrive, park and stay in your car or outside. We will call you when it is your turn to enter. You will be asked to fill out patient PPW through our website portal and email your medical card, vision card and picture ID 48 hours in advance of your appointment. Please bring your own face mask. We have a small fee for those that don’t have a mask. You will not be allowed to enter without a protective face mask. EVERYONE will have temperature taken. Please do NOT enter office without us taking your temperature. Hand Sanitizing: Please use the hand sanitizer at the entrance of the practice upon entry. Only the exam patient is allowed in the office. If you have guests with you, please have them wait in the car or outside. Exception: Minors with appointments may have (1) parent accompany them during the visit. Refrain from touching anything in the office and follow office protocol. Every frame sample will be properly sterilized before it’s returned to display so please leave in designated trays. Please use bathroom facilities BEFORE arriving at your appointment. Contact lens purchases will be direct shipped to you and glasses purchases will be delivered curbside. We have implemented several additional precautions our staff and doctors will be following as well. If you would like a full list of our internal policies regarding Covid-19 please go to www.eyeworksatlanta.com. Eyeworks has a strict cancellation/no show fee of $40 if not rescheduled or cancelled outside of 24 hours before appointment. Please sign below to acknowledge you have read, agree and will comply with out new policies and precautions. Signature*Date Name* Initials* COVID-19 QuestionnairePlease check all that apply.Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?* Yes No Have you or anyone in your household been tested POSITIVE for COVID-19?* Yes No Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?* Yes No Have you or anyone in your household traveled within the U.S. in the past 21 days?* Yes No Are you or anyone in your household a health care provider or emergency responder?* Yes No Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?* Yes No Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?* Yes No To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?* Yes No Signature*Date* Name* PhoneThis field is for validation purposes and should be left unchanged.