Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Although we prefer online submission of patient information, if you prefer to download, print and fill out our form to bring with you to your scheduled appointment, you can access our Patient Registration Form here.

Patient Information
Name*
Prefix First Middle Last Suffix
Date of Birth*
MM slash DD slash YYYY
Gender*
- Female
- Male
Occupation*
Email Address*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone*
Cell Phone*
Social Security Number (last 4 digits only!)*
How were you referred to our office?*
Referral Status - Other

Please let us know how you were referred to our office.
Have you been seen here before?*
- Yes
- No
Last Exam Date
What is the reason for your visit today?*
- Eye Exam
- Contact Lens Exam
- Office Visit
- Other
If other, please explain:
Do we have permission to contact you via e-mail or text message if necessary?*
- Yes
- No
OPTOS RETINAL IMAGING, OPTICAL COHERENT TOMOGRAPHY & MEIBOGRAPHY
We are proud to provide our patients with the state of the art digital scanning technology to have the best possible standard of care. These technologies allow our Healthcare professionals the ability to detect, diagnose, treat and manage various eye diseases including, but not limited to: Glaucoma, Macular degeneration, Diabetic retinopathy, Hypertensive retinopathy, Melanomas and Dry eye disease. Our Healthcare professionals require that all patients have a thorough examination of their retina each year.
- The OPTOS retinal imaging camera can be performed on dilated or non-dilated patients. It allows you the opportunity to see inside of your eyes just as the doctor sees it.
- Optical coherent tomography (OCT) is an imaging technique that uses coherent light to capture very high resolution 2 and 3-dimensional images of the retina.
- The Meibography is an imaging technology that allows us to evaluate the structures of the meibomian glands to detect dry eye disease.
Choose One*
- OPTOS Retinal Imaging $39.00
- Wellness Scan (OPTOS + OCT) $55.00
- Wellness Scan Plus (OPTOS + OCT + Meibography) $65.00
Eye History
Cataract
- Self
- Relative
Which relative has it?
Glaucoma
- Self
- Relative
Which relative has it?
Diabetic Retinopathy
- Self
- Relative
Which relative has it?
Macular Degeneration
- Self
- Relative
Which relative has it?
Retinal Detachment
- Self
- Relative
Which relative has it?
Dry Eye Disease
- Self
- Relative
Which relative has it?
Floaters/Flashes of Light
- Self
- Relative
Which relative has it?
Eye Injury/Trauma
- Self
- Relative
Which relative has it?
Eye Surgery
- Self
- Relative
Which relative?
Type of Surgery
Date of Surgery
Systemic History
HIV
- Self
- Relative
Which relative has it?
Cancer
- Self
- Relative
Which relative has it?
Diabetes
- Self
- Relative
Which relative has it?
Hypertension/Heart Disease
- Self
- Relative
Which relative has it?
Stroke
- Self
- Relative
Which relative has it?
Multiple Sclerosis
- Self
- Relative
Which relative has it?
High Cholesterol
- Self
- Relative
Which relative has it?
Asthma
- Self
- Relative
Which relative has it?
Thyroid Disease
- Self
- Relative
Which relative has it?
Seizures
- Self
- Relative
Which relative has it?
Kidney Disorder
- Self
- Relative
Which relative has it?
Ulcers/Gerd/Acid Reflux
- Self
- Relative
Which relative has it?
Sinus Problems
- Self
- Relative
Which relative has it?
Hearing Loss
- Self
- Relative
Which relative has it?
Hay Fever
- Self
- Relative
Which relative has it?
Emphysema
- Self
- Relative
Which relative has it?
Lupus
- Self
- Relative
Which relative has it?
Anxiety
- Self
- Relative
Which relative has it?
Depression
- Self
- Relative
Which relative has it?
Arthritis/Rheumatoid Arthritis
- Self
- Relative
Which relative has it?
Migraines
- Self
- Relative
Which relative has it?
Other
Tobacco Use*
- Yes
- No
Females: are you currently pregnant/nursing?
- Yes
- No
Breast feeding?*
- Yes
- No
Last Health Physical*
Please list all prescription and over-the-counter medications you take and for what conditions*
Please list all drug allergies you have*
Primary Insurance
I will be using Medical/Vision Savings Plan for this visit.*
- Yes
- No
Insurance Company Name*
Insured's Name*
First Last
Identification Number*
Insured's Date of Birth*
MM slash DD slash YYYY
Patient's Relationship to Insured*
Secondary Insurance
Do you have secondary insurance?*
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insured's Name
First Last
Identification Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relationship to Insured
Comments
If you have any comments you would like to add, please enter them here.
HIPAA Consent and Payment Authorization
I hereby authorize Dr. Kristine-Hue Van & Associates, Inc. to obtain my medical information to assist in the care of my health. This information may be disclosed and used to carry out my treatment, to obtain payment from insurance companies, and for health care corporations like quality reviews. I have been offered a copy of the clinic’s Privacy Notice for a more complete description of uses and disclosures before signing this consent. I understand that this clinic has the right to change their privacy practices and that I may obtain any revised notices from this clinic. I understand that I have a right to request a restriction of how my protected health information is used. I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed. I authorize any necessary medical treatment by the optometrist in this clinic. I further authorize this clinic to release or obtain any required medical information from my attending physicians or any medical facility.

Your insurance is meant to serve as a financial aid. We are happy to take assignment on your benefits. If you are not eligible for these benefits or are eligible for less than full coverage, your signature indicates that you agree to be financially responsible for the balance not paid by your plan. Our office staff will make every effort to verify benefits for you. VERIFICATION OF BENEFITS IS NOT A GUARANTEE OF PAYMENT. Payment for exam fees are due at the time of service. Insurance information must be presented before services are rendered. Professional fees cannot be refunded. I agree to pay any balances not covered by my insurance within 30 days. I am aware that I have 90 days from the date of service to finalize my contact lens prescription or for a spectacle prescription check without a charge.
Payment Authorization*
- I have read and agree to the above Payment Authorization Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Signature*
Email
This field is for validation purposes and should be left unchanged.

COVID Updates

The safety of our patients and staff members is our top concern. Dr. Kristine-Hue Van & Associates, Inc. has always followed universal precaution procedures and we continue to follow strict disinfection protocols. Please click here to read what to expect at your next appointment.

Patient Information

OPTOS RETINAL IMAGING, OPTICAL COHERENT TOMOGRAPHY & MEIBOGRAPHY

Eye History

Systemic History

Primary Insurance

Secondary Insurance

Comments

HIPAA Consent and Payment Authorization

Dr. Kristine-Hue Van and Associates, Inc.