';

1076 PATIENT INTAKE FORM

Fields marked with an * are required


OCULAR HISTORY


 

Help Text


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


 


FAMILY HISTORY


 

 

SOCIAL HISTORY


 


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.

Fundus photograph Consent


 

fundusOPTYX  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.

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