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.
Patient Full Name *

Prefix First Name Middle Name Last Name Suffix
Date of Birth *

Month Day Year
Date
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Home Phone Number *

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
What is your Gender? *

Male Female
Name of Parent/Guardian if patient 17 or younger
Parent/Guardian date of birth

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

None Cataract Plugs Lasik PRK Retinal Repair Eye Muscle
Are you currently taking any medication? *

Yes No
Check all health conditions you currently treat with medication: *

None Fatigue Heart disease High blood pressure Stroke Asthma COPD Gerd Acid Reflux Multiple Sclerosis Seizures Depression/Anxiety Type 1 diabetes Typle 2 diabetes Cholesterol Lupus Allergies
List your medications.
Do you have any medication allergies? *

Yes No Not Sure
List your medication allergies.
Do you use or do you have history of using illegal drugs? *
How often do you consume alcohol? *

Daily Weekly Monthly Occasionally Never
Do you use or do you have history of using tobacco? *
On average, how many hours per day do you spend on a computer/tablet/cellphone?
Do you have problems with day driving? *

Yes No
Do you have problems with glare? *

Yes No
Do you have problems with night driving? *

Yes No
What type of corrective eyewear do you currently wear? *

None Glasses Fulltime Glasses Part-time Contacts Prescription Sunglasses
Current Vision & Eye Problems *

None Cataract Distance blurry Color blindness Near blurry Diabetic retinopathy Floaters Dry eye Lazy eye Glaucoma Blindness Macular degenration
Current Vision & Eye Problems. *

None Cataract Distance blurry Color blindness Near blurry Diabetic retinopathy Floaters Dry eye Lazy Eye Glaucoma Blindness Macular degeneration
Click any eye issues that you experience on a regular basis. *

None Headaches Light sensivity TIred eyes Burning Dryness Watering Eye pain or soreness Irritation Itching Discharge Gritty or sandy feeling Redness

Family Vision & Eye History *

None

Father

Mother

Child

Sibling

Grandparent

Lazy eye

Blindness

Colorblindness

Eye Tumor

Glaucoma

Retinopathy

Macular Degeneration

Retinal Detachment

Eye turn

Family Health History *

None

Father

Mother

Child

Sibling

Grandparent

Rheumatoid Arthritis

Cancer

Diabetes

Heart Disease

Bloodpressure

Kidney Disease

Lupus

Stroke

Thyroid Disease

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.

Dilation, no charge Optomap Retinal Scanning - $32.00 (not covered by insurance) Neither, refuse eye health
Are you refusing to have your eye health checked by dilation or Optomap? *

No Yes, 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 to have your eye health examined by either dilation or Optomap you are accepting any and all risk for the possibility of not detecting these conditions and any long-term damage that is a result of your refusal.
Do you want to be tested for a new prescription (refraction)?

No I understand I will not have receive a prescription for glasses or contacts. Yes- $25.00 If you are unsure if your insurance covers the refraction, you may contact our office.
Do you want to be fit with contact lenses?

No Yes - 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.
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,
Today's Date

Month Day Year
Date Hour Minutes AM/PM Option
Signature *

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Patient Paperwork

Medical and Eye History

Authorization and Consent Form