Name: Advanced Eyecare Solutions
Address: 1808 Richards Rd, Ste 110, Bellevue, WA, 98005, US
Telephone: 425-283-0440
Price range: $000 - $300

Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Sex*
- M
- F
SSN*
Emergency Contact
Emergency Phone
Physician’s Name
Physician’s Phone
Home Phone
Cell Phone*
Work Phone
Email Address
Hidden
Date
MM slash DD slash YYYY
Have you been to our office before?
How did you hear about us?
How can we make your visit the best you’ve ever had?
What sports/hobbies do you enjoy?
How many hours per day are you on the computer?
Reason for today’s visit?
Date of last exam?*

If you don't remember, please enter approximately how long ago like 1 year, 2 years ago, etc.
Contact lens info
Do you currently use contacts?*
- Yes
- No
What type? (select one in each row)
- Hard RGP
- Soft Disposable
- OrthoK
- Daily
- Bi-Weekly
- Monthly
- Sphere
- Toric/Astigmatism
- Bifocal
- Other
Age of current contacts?
Are you interested in getting contacts today?
- Yes
- No
Glasses info
How old are your current glasses?*
Are you interested in getting new glasses/contacts today*
- Yes
- No
Ocular Health: Questions regarding your eyes.
1. Have your eyes ever been dilated?*
- Yes
- No
If so, How Long ago?
2. Have you ever had an eye infection, disease, injury, or surgery?*
- Yes
- No
Explain
3. Are you unusually sensitive to light?*
- Yes
- No
4. Do you ever see double?*
- Yes
- No
Explain
5. Do you have trouble with night vision?*
- Yes
- No
6. Do you have unusually frequent or severe headaches?*
- Yes
- No
When and Where?
7. Do you have blurred vision?*
- Yes
- No
When
Do you have any of these dry eye symptoms? (check all that apply)*
- Contact lens intolerance
- Redness
- Itchiness
- Stinging
- Burning
- Tearing
- Dryness
- Frequent Styes
- None of the above
Medical Health Family History: Questions regarding your medical health and family history. Please Check All that apply

Anyone in the family or yourself have been diagnosed with the following in the past or present.
Diabetes Type I*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Diabetes Type II*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
High Blood Pressure*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Thyroid Problems*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Cancer*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Heart Disease/Attack*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Kidney Trouble*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Respiratory Problems*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Liver Disease*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Psychiatric Care*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Hepatitis (A, B, C, D, E)*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Anemia*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Fainting/Dizzy Spills*
- None
- Myself
- Father
- Mother
- Bro
- Sis
- Other
Specify
Other
Please list any medication allergies*
Please list any other allergies*
Please list any medications you are currently taking and doses*
Social History
Do you drink alcohol ?*
- Yes
- No
How much?
Do you use tobacco?*
- Yes
- No
How much?
Do you use any other substances or recreational drugs?*
- Yes
- No
What?
Financial Agreement
*
I understand that all copayments, deductibles, or charges over the maximum benefit amount allowed by my insurance is due at the time of service.
*
I understand that all charges, regardless of insurance coverage, are ultimately the responsibility of the patient. If for any reason, payment is denied by my listed insurance company, the office will seek payment from me. Any benefits or pre-authorizations are not a guarantee of payment.
*
By signing below, I agree that I am financially responsible for any balance owed that is not covered by insurance. My signature also certifies that the information on this form is true and correct.
Health Information Protection*
- I have read and agree to the Privacy Policy
Signature of Patient or Party Responsible
Retinal Photo Consent
We recommend dilation every year with a comprehensive exam, however for patients who do not want to be dilated, photos are recommended.
Dilation:

Pros:

Most comprehensive retinal evaluation. Dilation makes the pupil larger which gives us a better view of the retina. When the eyes are dilated we can see straight back which is where the nerve and macula are as well as far into the periphery of the eye.

Cons:

Dilation causes blurry vision up close for about 2-3 hours. Dilation will also make you light sensitive (we have disposable sunglasses in office to counteract this effect).

Retinal Photos:

Pros:

You get to see inside of your own eye allowing you participate in your own care. There is a permanent record of exactly how your eye looks to compare year to year.

Cons:

We do not see as much area of the retina as with dilation.
PLEASE SELECT ONE OF THE FOLLOWING OPTIONS*
- I authorize Advanced Eyecare Solutions to take Retinal photos instead of dilation. I understand there is $40 fee that is not covered by insurance.
- I do not want to be dilated today and refuse to get retinal photos taken as an alternative.
- I would like to be dilated today for a comprehensive health assessment.
Hidden
PLEASE SELECT ONE OF THE FOLLOWING OPTIONS*
- I authorize Advanced Eyecare Solutions to take Retinal photos instead of dilation. I understand there is $40 fee that is not covered by insurance.
- I do not want to be dilated today and refuse to get retinal photos taken as an alternative.
- I would like to be dilated today for a comprehensive health assessment.
Signature

Contact lens info

Glasses info

Ocular Health: Questions regarding your eyes.

Medical Health Family History: Questions regarding your medical health and family history. Please Check All that apply

Anyone in the family or yourself have been diagnosed with the following in the past or present.

Social History

Financial Agreement

Retinal Photo Consent

Advanced Eyecare Solutions