Patient Intake Form

Patient Paperwork

The following information is required to be completed for all new patients and updated on a yearly basis for current patients.
Full Name*

PrefixFirst NameMiddle InitialLast NameSuffix
Date of Birth*

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Other Phone Number
What is your Gender?*

MaleFemale
Race*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteDecline to Specify
Name of Parent/Guardian
Parent/Guardian date of birth

MonthDayYear
Date
What pharmacy do you use?*
Pharmacy location
Who is your primary care physician?*
Medical and Eye History
Check any eye surgery that you have undergone:*

NoneCataractPlugsLasikPRKRetinal RepairEye MuscleOther
Check all health conditions you currently have :*

NoneFatigueHeart diseaseHigh blood pressureStrokeAsthmaCOPDGerdAcid RefluxMultiple SclerosisSeizuresDepression/AnxietyType 1 diabetesType 2 diabetesCholesterolLupusAllergiesOther
Do you have any medication allergies?*

YesNoNot Sure
List your medication allergies.
Are you currently taking any medication?*

YesNo
List your medications.
Current Vision & Eye Problems.*

NoneCataractDistance blurryColor blindnessNear blurryDiabetic retinopathyFloatersDry eyeLazy EyeGlaucomaBlindnessMacular degenerationOther
Click any eye issues that you experience on a regular basis.*

NoneHeadachesLight sensivityTired eyesBurningDrynessWateringEye pain or sorenessIrritationItchingDischargeGritty or sandy feelingRednessOther

Family Vision & Eye History*

	None	Father	Mother	Child	Sibling
Lazy eye
Blindness
Colorblindness
Eye Tumor
Glaucoma
Retinopathy
Macular Degeneration
Retinal Detachment
Eye turn

Family Health History *

	None	Father	Mother	Child	Sibling
Rheumatoid Arthritis
Cancer
Diabetes
Heart Disease
Bloodpressure
Kidney Disease
Lupus
Stroke
Thyroid Disease

How often do you consume alcohol?*

NeverOccasionallyDailyWeeklyMonthly
Do you use or do you have history of using tobacco?*
Do you use or do you have history of using illegal drugs?*
On average, how many hours per day do you spend on a computer/tablet/cellphone?
Do you have problems with day driving?*

YesNo
Do you have problems with glare?*

YesNo
Do you have problems with night driving?*

YesNo
What type of corrective eyewear do you currently wear?*

NoneGlasses FulltimeGlasses Part-timeContactsPrescription SunglassesOther
Height*
Weight*
Current Vision & Eye Problems*

NoneCataractDistance blurryColor blindnessNear blurryDiabetic retinopathyFloatersDry eyeLazy eyeGlaucomaBlindnessMacular degenrationOther
Authorization and Consent Form
Eye Health Dr. Cowan will examine the inside of your eyes for signs of eye diseases and cancers, heart disease, high blood pressure, diabetes, stroke, RA, multiple sclerosis, cholesterol, certain brain tumors and more. NOTE: patients 9 & younger ARE REQUIRED TO BE DILATED*

Dilation, no additonal chargeOptomap Retinal Scanning - $34.00 (not covered by insurance)Neither, I understand as a direct consequence of this refusal, Dr. Cowan may not be able to detect cases in which the retina is diseased, physically compromised or harboring tumorous growths. Accordingly, the process of early detection and diagnosis of certain eye conditions, eye diseases, and systematic diseases may be hindered and timely referral to a specialist and effective treatment may not be possible. By refusing dilation or Optomap you are accepting any and all risk for the possibility of not detecting these conditions and any long-term damage.
Do you want to be tested for a new prescription (refraction)?*

No I understand I will not receive a prescription for glasses or contacts.Yes- $30.00 If you are unsure if your insurance covers the refraction, you may contact our office. Medicaid (unless secondary to Medicare), Tricare (if eligible) & VSP insurances cover this fee.
Do you want to be fit with contact lenses?*

NoYes - $70 - $175 due at the time of check-out. There are additional tests and office visits required in order to be fit with contact lenses REGARDLESS if you are a current contact lenses wear. For this reason, our office charges a professional fee that ranges from $70- $175 to cover these tests and follow-up visits. This fee is separate and in addition to the cost of the routine exam. VSP plans offer a discount and/or allowance towards the fitting fee.
Release of Information *
I hereby authorize Thomas Vision Clinic to release any information necessary to my insurance company for payment on my behalf. I authorize the release of medical information for the purpose of patient referral should I be referred.
Patient Financial Agreement*
I agree to be responsible for any of pocket expenses, copays, deductibles, Optomap, refraction, contact lens professional fee & all other non-covered procedures I elect to have performed. A copy of the financial disclosure statement is available to me upon request.
Medical Care Authorization*
I am authorizing Dr. Cowan to provide me with medical care that is thought to be in my best interest. I understand I may refuse in writing any service or services discussed with me.
Notice of Privacy Practices*
The Thomas Vision Clinic Privacy Practice Notice has been made available for me to review which describes how my information may be disclosed. A copy of this notice is available to me upon request.
Authorized Persons
List person(s) you authorize to receive and discuss information regarding your personal health/medical information on your behalf.
Patient Instructions -
1. Our office is small and cannot accommodate proper seating for those not on the schedule. If possible we ask that only the patient and 1 guardian arrive for the appointment.
2. Do not arrive early to your appointment. Arriving early will only increase your wait time.
3. Have your insurance card and photo ID ready for check-in.
4. Remember to bring all of your eyewear with you to your appointment.
5. If you're not feeling well or have a fever the day of your appointment, please call us to reschedule.
6. If we do not receive communication from you to cancel or reschedule an appointment, there is a $25 no show fee charged.
Have you read the above required appointment guidelines?*
Signature*

Clear
Type Name of Signee *

First NameLast Name
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Patient Paperwork

Medical and Eye History

Authorization and Consent Form