If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Date of scheduled exam

First Name *

Last Name *

Address 1 *

Address 2

City *

Zip / Post Code *

Contact Email *

Contact Phone *

Date of Birth *

OCULAR HISTORY

Have you ever had an eye exam? *

Do you currently wear glasses? *

Do you currently wear contact lenses? *

MEDICAL HISTORY
Starting 3/27/2016, any necessary medication needs to be e-prescribed to pharmacies. Failure to provide proper pharmaceutical information will result in delay of e-prescriptions

Approximate date of last medical exam Help Text

Medical doctor

Name of your Pharmacy

Pharmacy Address

Pharmacy Phone

Do you have any allergies or allergic to medication? *

Are you taking any medications? *

Have you had any major injuries / surgeries / hospitalizations? *

FAMILY HISTORY

SOCIAL HISTORY

Do you drink alcohol? *

Do you currently smoke? *

INSURANCE

Do you have VISION INSURANCE? *

Do you have MEDICAL INSURANCE? *

Dilation consent

An important part of an eye exam is the dilated retinal examination. It involves putting dilation drops in the eyes to evaluate the health which include the retina, optic nerve and macula. It assists in detection of retinal disease, cataracts, glaucoma, retinal detachments, retinal breaks, macular degeneration and other important degenerative conditions.

Please choose an option *

YES, I choose to have my eyes dilated at the scheduled exam
I would like to reschedule the procedure to a different day understanding that a copay or charge for a separate visit may apply
NO, I choose not to have my eyes dilated at the scheduled exam, understanding that a condition with potential for vision loss may exist and go undetected

Fundus photograph Consent

OPTYX is pleased to provide high-resolution digital phtograph imaging to you our patient. Our DIGITIAL RETINOGRAPHY SYSTEM enhances your exam by providing a detailed visual record to document the current appearance of your retina. These screening images are beneficial in documenting healthy eyes as well as in aiding in early detection of certain retinal conditions. We encourage all of our patients to have this procedure to establish a point of reference for future examinations. Screening photos are offered as a service to our patients as we aim to provide the highest level of eyecare.

We offer this service for a nominal fee of $45.00. It should be noted that the High-Res digital images do not replace eye dilation, however, in many cases pupil dilation is not needed to obtain the pictures.

Please choose an option *

YES, I do wish to have a retinal photography performed
NO, I decline the retinal photography
Would like to review with the doctor before making a decision

Agreements

By checking the box and initialing my name below, I acknowledge that I have reviewed OPTYX's notice of privacy practice (shown prior to entering this form). I further consent to the release of my health information for purposes of treatment, payment and health care operations and as authorized or required by law under the circumstances described in the notice of privacy practices. OPTYX will not share your information with third party

Please input your initials *

I agree *

reCAPTCHA *

Check this box if would like a copy of this form sent to your email

2009 PATIENT INTAKE FORM

Prior to coming into our office, please confirm that we do accept your insurance. If you already have confirmed, please continue with this form.