Fowle Eye Care Associates, PLC

Ocular Coherence Tomography (OCT)
OCT technology is a new, state-of-the-art way to analyze and document the optic nerve and retina inside the eye. This quick, painless scan can give the doctor additional insights into eye diseases such as glaucoma, diabetes, macular
degeneration and more.

This "iWellness" test allows for earlier detection of these potentially sight
threatening conditions and offers information the doctor was previously unable to see with conventional techniques. This test, however, is not included in your vision or medical plan, and as a result, a $35.00 fee will be your responsibility for this enhanced level of service. For patients newly or previously diagnosed with related ocular conditions, the test can then be billed to medical insurance plans.

The doctors at our office recommend the iWellness scan be performed on all adult patients. For questions on the scan please ask any Fowle Eyecare staff member and they will be happy to assist you.
Yes, I would like to have the iWellness scan performed as part of my exam today, and understand the fee is $35.00.

Yes
No, I choose not to have the scan at this time.

No
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Privacy Practices Patient Acknowledgement Form
I acknowledge that I was offered a copy of Fowle Eyecare Associates,-PLC Notice.of Privacy Practices. A Copy is provided in the waiting room. If you would like a copy please let us know.

This notice provides an understanding of the uses and disclosure of my Protected Health Information, in plain language.

I understand that this practice reserves the right to change those.terms of its Notice of Privacy Practices and will provide me with a revised Notice of Privacy Practices upon request.
Patient Name: *
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Signature (If under 18, signature of parent or guardian) *

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The following person(s) are authorized to receive my personal medical lnformation. The following person(s) listed will also be able to pick up any supplies, eyeglasses, contacts, or other items deemed necessary.
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Signature: (If under 18, signature of parent of guardian) *

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COVID-19 Safety Form

For the safety of all and to help stop the spread of COVID-19:
Do you have, or recently had, a fever, cough, fatigue, shortness of breath, muscle aches or pain, dizziness, confusion, headache, sore throat, lack of appetite, airway bleeding, runny nose, chest pain, diarrhea, nausea and vomiting, loss of sense of smell, presence of conjunctivitis, recent travel to affected areas, and/or contact with sick individuals?

Yes No
Have you been tested for COVID-19?

Yes No
Have you been in close proximity to anyone tested for COVID-19?

Yes No
If Yes, to either question, please tell us the result
While in the office, please maintain a safe distance between you and others of at least six feet and avoid touching surfaces and your face. Thank you for helping us keep everyone safe and healthy.

I have fully informed these health care providers of my entire medical condition so that they can exercise their professional judgment regarding my care.
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Thank you for choosing us as your eye care provider