Adult Patient Intake Form

Primary Vision Insurance
Insurance Name*

Vision Service Plan (VSP)Vision Care Direct (VCD)No Vision InsuranceOther
Insurance ID:
Insurance Policy Group:
Is the patient the policy holder?

YesNo
If no, please provide the policy holder's information below:
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Gender
Relationship to Insured
Policy Holder's SSN
Full SSN or last 4 digits
Policy Holder's Employer
Phone Number
Optional: Upload front and back images of card

Browse Files

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Retinal Evaluation
Retinal Examination Options:
As part of your comprehensive eye examination, it is essential to evaluate your retina to ensure optimal eye health. You have two options for this examination: Optomap or Dilation.

Optomap:
- Recommended by Our Doctor: We recommend Optomap for a healthier, smoother, and safer experience.
- Patient Preference: Over 90% of our patients prefer Optomap.
- Advanced Technology: Allows for early detection of eye diseases.
- Future Tracking: Images can be stored and compared over time to monitor changes in your eye health.
- Quick and Convenient: The process is faster, allowing you to complete your visit more quickly.
- No Side Effects: Your vision will not be affected so you can continue your day without issues like glare sensitivity or compromised vision.
Dilation:
- Additional Time: Please allow an extra 30 minutes for the drops to take effect.
- Physical Discomfort: The drops may cause temporary burning and stinging.
- Side Effects: May cause difficulty driving, glare sensitivity, and temporary blurred vision lasting 6-8 hours.
Note: Children under 5 years old require dilation to accurately assess early childhood development.
A retinal evaluation is required for all exams. Please select one of the following options:*

Optomap (Insurance may cover at a $0-39 copay range)Dilation

Contact Lenses
Do you need a contact lens prescription?*

Yes - Service fee is $250 or VSP CopayNo, but interestedNo, not interested

If you are a current contact lens wearer:

	Answers
What brand of contacts do you wear?
How often do you sleep in your contacts?
How often do you replace your contacts?
Do you have back up glasses?

	Yes	Date
Lasik / PRK / RK
Cataract / RLE Surgery
Retinal Hole / Detachment Repair
Eye Injuries
Other

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