Dry Eye Eval Intake

Name (Must Match your Insurance Card)* This field is required.

First Name

Last Name

Date of Birth* This field is required.

Date

Email* This field is required.

example@example.com

What is your relationship to our office?* This field is required.

New- Referred Here by Doctor

New- Found you online/Word of Mouth

Established- Dr. D recommended this evaluation at another exam.

Established- I asked for a Dry Eye Evaluation

Name of Referring Doctor Please type City and Office name, as well as phone or fax if you have it.

What type of visit are you here for today?* This field is required.

Initial Dry Eye Evaluation

Post-treatment Dry Eye Evaluation

Dry Eye Follow-up

Treatment Day

Is today's appointment your first treatment day?* This field is required.Please complete the relevant informed consent documents for your treatment.

YESNO

Which treatment package are you completing?* This field is required.

Gold Dry Eye (RF, IPL, LED, Microcurrent, Cleanses, Expression) [$3,000 up front]

Silver Dry Eye (RF, IPL) [$2,000 up front]

Mixed Gold/Silver Package (2 of Each Above Visit) [$2675 up front]

Just the Inflammation (IPLx4) [$1,520 up front]

Just the Glands (RFx4) [$1,040 up front]

No treatment package selected/I need help.

Maintenance RF/IPL ONE Session (Full Price)

Choose how you want to pay for your treatment* This field is required.Payment for entire treatment package is due at first treatment day. If paying per visit, a la carte prices apply. Packages are the only way to get the best deal and an additional treatment as per our menu.

I will pay today with cash or card.

I would like to sign up for financing.

I will pay a la carte.

I will pay/have paid up front for a package.

SEE ABN* This field is required. Dry Eye Treatments and procedures are not always billable to Insrance companies.This ABN is to inform you of the procedures and tests that are not always covered so that you are able to make an informed choice about your treatment. We will not bill these dry eye procedures to your insurance under any circumstances.

IPL Consent Form* This field is required.

Radiofrequency Consent Form* This field is required.

Please tell us about your dry eye symptoms* This field is required.DEQ Survey for Dry Eye Symptoms helps us quantify how your dry eye affects YOU daily. Please consider each of the questions as it relates to your dry eye specifically. HOW OFTEN DO YOU EXPERIENCE THE FOLLOWING 0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Please tell us about your dry eye symptoms* This field is required.DEQ Survey for Dry Eye Symptoms helps us quantify how your dry eye affects YOU daily. Please consider each of the questions as it relates to your dry eye specifically. HOW OFTEN ARE YOU LIMITED IN PERFORMING THE FOLLOWING 0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Please tell us about your dry eye symptoms* This field is required.DEQ Survey for Dry Eye Symptoms helps us quantify how your dry eye affects YOU daily. Please consider each of the questions as it relates to your dry eye specifically. HOW OFTEN ARE YOU UNCOMFORTABLE IN THE FOLLOWING 0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

What eyedrops have you tried in the past?* This field is required.

Give a brief history of your dry eye - when did it start? Can you identify any thing that has made it worse (i.e cataract surgery, LASIK, COVID, etc?)?* This field is required.

Record your daily routine for dry eye- please include anything you do for your eyes to try to make them feel better. Lid cleansing, Artificial Tears, Warm compresses, Prescription Medications, etc)* This field is required.

What goal do you have for your dry eye treatment other than to feel better?* This field is required. Examples: Read for XX minutes, Drive independently, Less drops in a day, etc.

What treatments are you interested in receiving at our office?* This field is required.

Just interested in Dr. D's opinion - Not sure of treatments

Interested in over-the-counter options only

Prefer to stay with whatever insurance will cover

I am here for the interventional treatment - IPL, RF, etc.

Interested in medications

Please sign below to indicate that you have provided the answers to the best of your knowledge, and that you agree to the terms and conditions as laid out in these forms.* This field is required.

If you are a new patient with our office (including if you have not been seen in over two years), the jotform will take you to our online patient forms in another tab. Please complete the requested information there.