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.

Patient Information

Name*

Prefix First Middle Last Suffix

Date of Birth*

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

Are you planning to get new glasses today?*

Yes
No

Are you planning to get new contacts today?*

Yes
No

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 highly recommend 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 - Due to COVID 19, Photos is required at this time, doctors will dilate eyes if deem necessary
Wellness Scan (OPTOS + OCT) $55.00
Wellness Scan Plus (OPTOS + OCT + Meibography) $65.00

Eye History

Cataract

Self
Relative

Who has it?

Glaucoma

Self
Relative

Who has it?

Diabetic Retinopathy

Self
Relative

Who has it?

Macular Degeneration

Self
Relative

Who has it?

Retinal Detachment

Self
Relative

Who has it?

Dry Eye Disease

Self
Relative

Who has it?

Floaters/Flashes of Light

Self
Relative

Who has it?

Eye Injury/Trauma

Self
Relative

Who has it?

Eye Surgery

Self
Relative

Who has it?

Type of Surgery

Date of Surgery

Systemic History

HIV

Self
Relative

Who has it?

Cancer

Self
Relative

Who has it?

Diabetes

Self
Relative

Who has it?

Hypertension/Heart Disease

Self
Relative

Who has it?

Stroke

Self
Relative

Who has it?

Multiple Sclerosis

Self
Relative

Who has it?

High Cholesterol

Self
Relative

Who has it?

Asthma

Self
Relative

Who has it?

Thyroid Disease

Self
Relative

Who has it?

Seizures

Self
Relative

Who has it?

Kidney Disorder

Self
Relative

Who has it?

Ulcers/Gerd/Acid Reflux

Self
Relative

Who has it?

Sinus Problems

Self
Relative

Who has it?

Hearing Loss

Self
Relative

Who has it?

Hay Fever

Self
Relative

Who has it?

Emphysema

Self
Relative

Who has it?

Lupus

Self
Relative

Who has it?

Anxiety

Self
Relative

Who has it?

Depression

Self
Relative

Who has it?

Arthritis/Rheumatoid Arthritis

Self
Relative

Who has it?

Migraines

Self
Relative

Who has it?

Other

Tobacco Use*

Yes
No

Are you currently pregnant?*

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

If you ARE using a Medical or Vision Savings Plan for this visit please complete the insurance field below. If you are NOT using any savings plan type in 00000 in those fields.

I will be using Medical/Vision Savings Plan for this visit.*

Yes
No

Insurance Company Name*

If you ARE using a Medical or Vision Savings Plan for this visit please complete the insurance field below. If you are NOT using any savings plan type in 00000 in those fields.

Insured's Name*

First Last

Identification Number*

Insured's Date of Birth*

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

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.

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*

Comments

This field is for validation purposes and should be left unchanged.

Patient Registration Form

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.