Forms

New Patient Form – Optic Gallery Summerlin

Please fill out the entire New Patient Form. It will be sent to our office upon submission.

Step 1 of 3

Today's Date*

First Visit?*

Name*

Sex*

Age*

Date of Birth*

If married, Spouses Full Name

Spouse's Date of Birth

Parent's Date of Birth

Home Phone*

Mobile Phone*

Does your work require special vision needs?

If "Yes", please explain

Primary Insurance

Primary Insurance #

Vision Care Plan

Date of Last Exam*

Where

Doctor

Do you wear contact lenses?

Reason for Today's Visit? *

List Activities/Hobbies *

Medical History

Medical Doctor

How were you referred to Optic Gallery Summerlin? *

Date of Last Visit *

Have you ever had any of the following medical conditions? *

If you indicated "Other", please explain *

Do you?

Medications & Allergies

Medications *

Please list any you are taking or have taken in the past

Allergies *

Please list any allergies you have or have had in the past

Do you have a Family History of *

Ocular History

Do you have *

If you checked "Other Eye Disease", please explain

Step 2 of 3

Does anyone in your family have?*

If you checked "Other" under Ocular Conditions, please explain

Patient Information Acknowledgement *

In the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, I authorize Optic Gallery, Dr. Jordan, Dr. Radtke, or any of their associates to release and/or request these records. If applicable, I request that payment of authorized Medicare or other insurance be made either to me or on my behalf to Optic Gallery, Dr. Jordan, Dr. Radtke or any of their associates for any services rendered to me. I authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies. I understand that should my financial account become delinquent, it will be sent to collections where I will be responsible for any collections fees, attorney fees, and court costs. I UNDERSTAND I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY. It is the policy of this office to require: 1) Payment in full or at least one-half before the order can be placed. 3) All orders are final when placed. 2) The balance of the fee must be paid at the time the order is dispensed.

SIGNATURE (Parent or Guardian)*

Name*

Today's Date*

Step 3 of 3

Patient's Name*

Today's Date*

Acknowledgement Notice of Privacy Practices

Signing in this section signifies that you have received a copy of our Notice of Privacy Practices In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for these services, and to conduct healthcare operations involving our offices. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. Record Retention Policy We are informing you that our office will keep your records for 5 years from the date of this examination. If signing for a minor, please be aware that our office will only keep your child’s records for 5 years from the date of this examination

Consent *

Signature (Parent or Guardian)

Signature Date *

iWellnessExam & Digital Retinal Photography

The iWellnessExam is a quick, non-invasive scan that allows our doctors to see beneath the surface of your retina. This unique technology combined with digital retinal photos can help our doctors detect vision threatening conditions and systemic diseases in their very early stages, when they are most treatable. Our doctors recommend these tests as a routine part of the comprehensive eye exam for all of our patients. They are a great alternative if you would prefer not have your eyes dilated at this visit. The iWellnessExam and digital retinal photography are especially important if you or your family have a history of diabetes, high blood pressure, high cholesterol, headaches, cataracts, glaucoma, macular degeneration, or other eye conditions. These conditions can be monitored closer and more accurately with these tests. The cost of these procedures is $49. It is not routinely covered by insurance. Please ask our staff if you have any questions. Please select one of the options below, indicating your choice for the iWellnessExam and digital retinal photography:

Options *

Consent *

In the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, I authorize Optic Gallery, Dr. Jordan, Dr. Radtke, or any of their associates to release and/or request these records. If applicable, I request that payment of authorized Medicare or other insurance be made either to me or on my behalf to Optic Gallery, Dr. Jordan, Dr. Radtke or any of their associates for any services rendered to me. I authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies. I understand that should my financial account become delinquent, it will be sent to collections where I will be responsible for any collections fees, attorney fees, and court costs. I UNDERSTAND I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY. It is the policy of this office to require: 1) Payment in full or at least one-half before the order can be placed. 3) All orders are final when placed. 2) The balance of the fee must be paid at the time the order is dispensed.

Consent of Agreement *

SIGNATURE (Parent or Guardian) *

Date of Signature *