Patient Intake Form

Welcome to Scope Optometry!
Patient Name*

First NameLast Name
If patient is a minor, please provide the name of the authorized individual who will be signing the forms.

First NameLast Name
Please select the reason for your visit:*

Routine (annual) eye exam for glasses and/or contact lensesMedical visit (ex: pink eye, dry eyes, cataracts, diabetes, etc.)
Medical Visit Acknowledgement
Any eye problems outside the routine vision check for glasses is typically not covered by vision care plans. These issues are considered medical and your medical health insurance will be billed accordingly if applicable. You are responsible for any fees, deductibles, or copays for a specialist office visit, including all follow up visits. You may be charged the usual and customary fee if insurance information cannot be verified prior to your visit, and will be refunded accordingly if your plan covers some of the cost. Please click below to indicate your understanding that today's visit and follow up visits are not covered by vision care plans.*

I understand that today's examination is for medical reasons and that vision insurance will not cover this type of visit. I acknowledge that I am financially responsible for any charges and services not covered by my insurance (if applicable).
Financial and Privacy Policy
Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Please let us know if you have any questions or concerns.

Insurance. We participate in several insurance plans; all co-payments and deductibles must be paid at the time of service. If we are not in-network with your insurance company or no insurance information is provided at the time of service, payment in full is expected. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

No refunds on services and custom products. Payment in full is expected before any order is started. Prescription eyeglasses are custom products that are made to order specifically for you and cannot be returned. If there are any issues with the product, we will do our best to address them. All services rendered are provided on a non-refundable basis. You agree not to charge back any credit card payments for custom products or services rendered. In the event of a chargeback or other payment dispute, they will be considered to be in violation of this agreement and may be subject to collection to an outside collection agency.

The following pdf is a copy of our privacy policy. Please sign below to indicate that you have read and understand the financial and privacy policy and agree to abide by its guidelines.
Signature*

Clear
Date*

MonthDayYear
Date
Email Consent
I consent to having my eyeglasses and/or contact lens prescription sent to me electronically via email. I am aware of the risks associated with communicating health information via unencrypted email.*

YesNo

Insurance Authorization
Will you be using insurance for today's visit?*

YesNo
INSURANCE AUTHORIZATION - SIGNATURE ON FILE

GENERAL RELEASE OF INFORMATION

I give my permission to Scope Optometry to disclose any or all parts of the clinical record to my insurance company(s) for purposes of satisfying charges billed.

ASSIGNMENT OF INSURANCE BENEFITS AND NON-COVERED SERVICES

I hereby authorize payment of benefits directly to Scope Optometry. I understand and agree that I am financially responsible for any charges and services not paid by my insurance company(s).

I permit a copy of this authorization to be used in place of the original.
Signature*

Clear
Date*

MonthDayYear
Date

Contact Lens Policy
Will you be needing a contact lens exam/contact lens prescription renewal?*

YesNo
Pricing

A contact lens evaluation is an additional fee to the price of a comprehensive eye exam. The fee can range from $99 to $299 depending on the complexity of the fit. Insurance may cover a portion of this fee. (Please ask an associate for the specific details of your plan.) The price includes diagnostic lenses and follow-up phone calls/visits until your contact lens prescription is finalized, up to 90 days from the original exam date. This includes all follow up visits related to the fit of the contacts, and does not include medical visits that may be related to overwear or misuse of contact lenses. If you require a contact lens evaluation/follow up after your prescription has been finalized or past the 90 day period from your initial fit, you will be charged for the additional visit(s).

Procedures

By law in California, a contact lens prescription expires after one year. A contact lens evaluation (including prescription renewals) involves several steps and additional time, and can only be done after a comprehensive eye exam. However, it can be delayed up to 90 days from your last exam.
For the full disclosure of our policy, please read our contact lens policy below.
I have read and agree to the terms of the Contact Lens Policy, and I understand that there is an additional fee for the contact lens portion of the exam. I also agree to have my contact lens prescription emailed to me when it is finalized.*

Clear
Date*

MonthDayYear
Date

Retinal Screening vs. Dilation
What is OptoMap?

OptoMap captures ultra-wide images of the retina to show any signs of damage and abnormalities to the back of the eye. This instrument will also enhance our ability to screen for retinal defects relating to glaucoma, cataracts, and macular degeneration. Catching symptoms early on will prevent permanent sight loss.

Cost

We offer this procedure for $39. Some insurance plans cover the imaging, but most plans do not. (Please ask an associate for the specific details of your plan.)

No Dilation with OptoMap

This technology can be used without dilation and will be a permanent part of your medical records. There are no side effects with this procedure and only takes 2-3 minutes. While retinal imaging does not replace dilation, it provides the most comprehensive view of the retina without dilation available.

The doctor recommends the retinal screening for all patients every year.
Please accept or decline below whether you would like to proceed with the OptoMap retinal imaging at today’s examination.*

I prefer the optomap retinal screening over dilation and understand that there may be an additional co-pay.I do not want this done and understand that declining this procedure may limit the doctor’s ability to optimally assess my ocular health.

	1 Never	2 Rarely	3 Sometimes	4 Often	5 Always
Headaches: You get headaches of any severity each week (even just a dull ache counts). Your headaches tend to get worse later in the day.
Stiffness/pain in neck/shoulders: You experience stiffness/tension in your neck/shoulders when you work at a computer or read (this might even be from your posture).
Discomfort with computer use: You experience stiffness/tensions in your neck/shoulders when you work at a computer or read (this might even be from your posture).
Tired eyes: Your eyes feel increasingly fatigued/tired as the day goes on.
Dry eye sensation: Your eyes progressively feel more dry/sandy/gritty while working at the computer or reading.
Light sensitivity: Bright/strong lights (vehicle headlights, florescent lights, etc.) bother you.
Dizziness: You experience dizziness, motion sickness, or vertigo.

	0 Never	1 Sometimes	2 Often	3 Constant
Dryness, Grittiness, or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

	0 No Problems	1 Tolerable	2 Uncomfortable	3 Bothersome	4 Intolerable
Dryness, Grittiness, or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Welcome to Scope Optometry!

Medical Visit Acknowledgement

Financial and Privacy Policy

Email Consent

Insurance Authorization

Contact Lens Policy

Retinal Screening vs. Dilation

DRY EYE QUESTIONNAIRE. Dry eye disease is one of the most common reasons why patients visit eye doctors and we want to make sure to address your concerns. Please take a moment to thoughtfully answer the questions below.

Short Survey