GHFV Patient Intake Form

Name*

First NameLast Name
Birthdate*

MonthDayYear
Date

PATIENT INFORMATION
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number*

Area CodePhone Number
Email*
example@example.com
Gender*

MaleFemaleOther
Occupation
(in order to understand your daily visual tasks, which will help fine tune your prescription)

OPTOMAP DIGITAL RETINAL IMAGING
The Optometric Physicians at Gig Harbor Family Vision recommend our Digital Retinal Imaging system as the preferred method to examine the retina annually.

Digital Retinal Imaging provides:
- A more thorough view of the back of your eye (the retina)
- A digital record of the structures of your retina that becomes part of your medical record
Digital Retinal Imaging:
- It is fast, easy, non-invasive, and comfortable
- Helps detect early signs of eye disease (ie. glaucoma, macular degeneration, diabetes, retinal holes)
- Does NOT require dilation drops (which result in blurred vision and sensitivity to light for up to six hours), however, we may also ask that you allow us to dilate your eyes if we feel it is necessary.
Your exam provides you with routine vision screening procedures, but does not include advanced disease detection procedures like Digital Retinal Imaging.

The fee for this procedure is $40.00 at the time of your exam.
Please indicate your choice:*

I would like Optomap Digital Retinal Imaging for myself/my childI do not want Optomap Digital Retinal ImagingI would like to discuss this with my doctor

Office Policies and Notice of Privacy Practices
- Glasses prescriptions include follow-up visits for prescription checks, up to 3 months from your original exam date. After 3 months, an office visit fee is charged because other factors may influence prescription changes. We do not verify the accuracy of glasses ordered online and DO NOT provide pupillary distance measurements. Any problems after 6 months, require a new eye exam.
- I have seen a copy of the HIPAA Notice of Privacy Practices from Gig Harbor Family Vision and/or I am aware a copy of the practices can be provided by request or are viewable online.
- IMPORTANT: To provide the best care, if you are unable to make your appointment we ask that you call to cancel your appointment at least 24 hours in advance or a $40.00 NO SHOW/LATE CANCELLATION fee will be charged. In order to reschedule, this fee is collected.
- Arriving 15 minutes late may require rescheduling your appointment.
Contact Lens Policy

Gig Harbor Family Vision has established a set of procedures in order to provide the highest level of contact lens care for each patient. We are committed to making your contact lens wearing experience as enjoyable as possible which includes prescribing the right contact lens for your goals.
1. All first time contact lens wearers or patients who have difficulty with insertion and removal will go through a training session. A $30 fee is required, in addition to the assessment fee, and the session will be scheduled on a separate visit. This ensures we have the correct contact lens trials needed and the 45 minute time slot to adequately perform the training.
2. Patients may require necessary follow-ups within 1-2 weeks. This is to ensure the patient and doctor are satisfied with vision and comfort. Once the patient and doctor agree that the contact lenses are performing as expected, the doctor will finalize and write the contact lens prescription. The assessment fee includes up to 3 follow-ups within a 2 month period. Any follow-up visits after 2 months have passed may be subject to an office visit fee. Note: If a follow up is necessary, please wear your contact lenses to your appointment.
3. A copy of a contact lens prescription will be provided electronically to the email address on file once the doctor finalizes the contact lens prescription. A paper copy will also be provided at the conclusion of the contact lens assessment
4. Included in the contact lens assessment are a set of biweekly or monthly soft lens trials or up to 10 days of daily contact lenses. NO extra trials will be given at the conclusion of the assessment. It is the patient's responsibility to order their supply once given a finalized contact lens prescription.
Note: Patients currently wearing rigid gas permeable (hard) lenses, please allow up to 24 business hours for the doctor to consult with the lab if changes are made to your prescription. A follow-up in 1-2 weeks is necessary to assess the new lenses after your order has arrived.

If you experience problems with your contact lenses, please remove them and contact our office immediately.
By clicking here, I acknowledge that I have read and agree to the contact lens policy outlined above.
Release of records: the listed individuals are authorized to receive my protected health information (such as my prescriptions). I am aware that I can revoke the authorization at any time, but must do so in writing.

No personsSpouse/PartnerChildren
By signing below, I acknowledge I have read the entirety of this form, I am aware and agree to the office policies of Gig Harbor Family Vision, and have reviewed their HIPAA privacy policies.
Name*
If patient is a minor, guardian name here
Today's Date*

MonthDayYear
Date
Signature (PLEASE COMPLETE)

Clear
Should be Empty:

PATIENT INFORMATION

Financial Agreement and Insurance Information

HEALTH HISTORY

OPTOMAP DIGITAL RETINAL IMAGING

Office Policies and Notice of Privacy Practices