Patient Form

Patient Form

Contact Information

Employer Information

Person who holds primary health insurance (or vision) insurance:

Person who holds secondary health (or vision) insurance:

Primary Care Provider

Medications

Allergies to Medication

Prior Eye Related Injuries or Surgery

Have you had or currently have any of the following conditions?

Eyes

Constitutional Symptoms

Ears/Nose/Mouth

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurological

Psychiatric

Endocrine

Hematology/Lymphatic

Allergy/Immunology

Surgeries & Dates

Family Medical History

Other Information

Vision Lifestyle

Retinal Camera or Dilation

A new highly sophisticated, computerized assisted digital camera in our office enables us to provide a very detailed retinal analysis of your eyes. Retinal photography can document and record problems associated with Diabetes, High Blood Pressure, Cancer, Cataracts, Glaucoma, Macular Degeneration, etc. Typically, our doctors will dilate your pupils with eye drops to analyze your eyes for these concerns. For many patients, Retinal Photos will take the place of the Dilation, and you will not leave our office with uncomfortable, blurry vision or light sensitivity. If our doctor finds something of medical significance in your eyes while taking these photos, we will bill your medical insurance for this service. If there are no medical findings, you will be charged $40. These images will remain in your electronic chart for years to come, and will serve as a baseline as you age. The doctors in our office highly recommend Retinal Photos!

Confirmation