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
*
Mr.
Mrs.
Dr.
Ms.
Miss
Master
Prefix
First Name
Middle Initial
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
Phone Number
*
Other Phone Number
What is your Gender?
*
Male
Female
Race
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Decline to Specify
Name of Parent/Guardian
Parent/Guardian date of birth
-
Month
-
Day
Year
Date
What pharmacy do you use?
*
Pharmacy location
Please Select
Leesville
DeRidder
Many
Alexandria
Natchitoches
Rosepine
Lake Charles
Pineville
Shreveport
Other
Who is your primary care physician?
*
Medical and Eye History
Check any eye surgery that you have undergone:
*
None
Cataract
Plugs
Lasik
PRK
Retinal Repair
Eye Muscle
Other
Check all health conditions you currently have :
*
None
Fatigue
Heart disease
High blood pressure
Stroke
Asthma
COPD
Gerd
Acid Reflux
Multiple Sclerosis
Seizures
Depression/Anxiety
Type 1 diabetes
Type 2 diabetes
Cholesterol
Lupus
Allergies
Other
Do you have any medication allergies?
*
Yes
No
Not Sure
List your medication allergies.
Are you currently taking any medication?
*
Yes
No
List your medications.
Current Vision & Eye Problems.
*
None
Cataract
Distance blurry
Color blindness
Near blurry
Diabetic retinopathy
Floaters
Dry eye
Lazy Eye
Glaucoma
Blindness
Macular degeneration
Other
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
Other
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?
*
Never
Occasionally
Daily
Weekly
Monthly
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Occasionally
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
On average, how many hours per day do you spend on a computer/tablet/cellphone?
Please Select
Less than 1 hour
1 - 2 hours
2 -3 hours
>3 hours
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
Other
Height
*
Weight
*
Current Vision & Eye Problems
*
None
Cataract
Distance blurry
Color blindness
Near blurry
Diabetic retinopathy
Floaters
Dry eye
Lazy eye
Glaucoma
Blindness
Macular degenration
Other
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 charge
Optomap 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?
*
No
Yes - $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
*
Please Select
I Agree
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
*
Please Select
I Agree
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
*
Please Select
I Agree
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
*
Please Select
I Agree
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 -
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.
Do not arrive early to your appointment. Arriving early will only increase your wait time.
Have your insurance card and photo ID ready for check-in.
Remember to bring all of your eyewear with you to your appointment.
If you're not feeling well or have a fever the day of your appointment, please call us to reschedule.
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?
*
Please Select
Yes, I have read the appointment guidelines
Signature
*
Clear
Type Name of Signee
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: