Eye History: Do you have or have you ever had any of the following problems:
Loss of Vision
(Mother, Father, Grandparents, Siblings)
High Blood Pressure
Other Eye Disease or Condition:
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Not Hispanic or Latino
Hispanic or Latino
Are you interested in correcting your vision with LASIK Surgery?
PATIENT HISTORY QUESTIONNAIRE
(completion required at each patient appointment)
Last eyecare provider:
Date of last eye exam
Are you currently having eye or vision problems?
If yes, please explain
Do you wear glasses?
How old are they?
Are they bifocals?
Are they for
Have you ever worn contact lenses?
If yes, when were they prescribed?
Do you wear contacts now?
If not, why did you quit?
Are you interested in wearing contact lenses?
1. Specific curvature measurements of the corneas
2. Evaluation of current and new lenses to ensure optimal fit, vision and comfort
3. Medical assessment of the cornea, tear film and conjunctiva as they relate to contact lens wear
4. Instructions regarding safe contact lens wear, care and proper cleaning and solutions
5. Contact lens follow up care for 90 days
If you have any questions, please do not hesitate to speak with your doctor.
Payment for all services and products is the responsibility of the patient.
I agree to pay all copays, deductibles, co-insurances and non-covered services as determined by my insurance company.
I understand there is a returned check fee applied to every returned check.
I agree to pay an additional collection fee for all accounts not paid in the time stated on the final monthly statement.
I authorize the release of medical information concerning my illness and treatment by Clarkson Eyecare to my insurance company.
I also authorize the release of my personal medical information to any doctor whom I may be referred to.
I understand verification of eligibility is not a guarantee of payment as stated by my insurance company.
I authorize payment of my insurance benefits to Clarkson Eyecare.
We will file all insurance forms if Clarkson Eyecare is a participating provider for your plan.
We will supply you with an itemized statement which you may submit to your insurance carrier.
PAYMENT IN FULL IS REQUIRED AT TIME OF SERVICE
If yes, please read the following information regarding contact lenses.
Clarkson Eyecare prescribes quality contact lenses to improve your vision and your lifestyle. Contact lenses are FDA regulated medical devices that can cause discomfort, infections, and even permanent vision loss if not cared for properly. New and existing contact lens wearers require additional time and testing during an eye examination to minimize the risk of serious eye problems. This additional testing is only done for contact lens wearers, not for patients who do not wear contact lenses. For this reason, there are additional contact lens evaluation and services fees for new and existing contact lens wearers. Your contact lens evaluation and services fee includes:
Do you drive?
If yes, do you have visual difficulty when driving?
If yes, please describe:
Current Every Day Smoker
Current Some Day Smoker
Smoker (Current Status Unknown)
Do you drink alcohol?
Do you use illegal drugs?
Have you ever been exposed to or infected with:
If patient is 18 or under, please complete:
Any prenatal, perinatal, or postnatal problems?
Any developmental problems?
Do you have any concerns with your child's school performance?