Oasis Optometry- Patient Intake Form (new/revised)

Patient Intake Form

Please fill in the form below prior to your visit. For returning patients, we require all information to be updated yearly.
Full Name *

First NameMiddle NameLast NameSuffix
Email
example@example.com
Date of Birth *

MonthDayYear
Sex*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about us?*

Internet searchInsurance PanelYelpFacebook/InstagramFamily/FriendReturning PatientOther

What is your vision insurance?*

None (private pay)VSPMESSuperiorOther
If you are not the primary insurance holder, please provide the name of the primary holder, their birthdate, and last four of SSN.
What is your medical insurance? *
Medical Insurance ID number
Last 4 digits of YOUR SSN (*this allows us to verify your insurance benefits*)
I consent that my insurance will be billed for my visit. If my insurance does not pay, I understand that I will be responsible for all charges.*

Yes, I consentI will not be using insurance for today's visit

Our office utilizes modern imaging technology to evaluate the health of the retina. The Eidon imaging system provides an ultra-widefield image of the retina without having to dilate the eyes, which means there are no side effects to the patient.

The Eidon Ultra Wide Field imaging system is recommended for every patient, every year. Benefits of this service include:
- Establishing a baseline image of the retinas, to track for potential changes over time.
- Detection of eye conditions including retinal holes/tears/detachments, floaters, diabetic and hypertensiive changes, macular degeneration, glaucoma, etc.
- Can be performed without dilation. Normally, when the eyes are dilated, the side effects are light sensitivity and blurred vision which can last 3-4 hours. If pathology is seen the Eidon Ultra Wide Field imaging system, a dilated exam will be performed.
- Saves time. Image acquisition is quick, while dilation takes 20 minutes.
This service ($39) is not covered in full by some insurance plans.
Please check the box below:*

I would like the Eidon imaging performed todayI would like to opt-out or discuss further with the doctor

Patient Notice
I consent that exam records such as (referrals, medications Rx, glasses/contact lenses prescription) can be sent to me digitally via email.*

Yes, I agreeNo
I have read and agree to the office's privacy policy. (Parents/guardians please sign for minor). Add a digital signature using your mouse, stylus, or finger. *

Clear
Should be Empty:

Patient Intake Form