Race*
Right Eye:
Left Eye:
Patient's First Name
Local Address
E-mail Address
Sex
Date of Birth
ID Number
NONE
NONE
NONE
NONE
NONE
NONE
NONE
NONE
NONE
NONE
NONE
NONE
NONE
Retinal detachment
Macular degeneration
Medical Plan
Nature of injury:
Glaucoma
Do you drink alcohol?  
Do you smoke?    
Initial
Marital Status
Person Reponsible For Payment
Insured's Date of Birth
Relationship to Insured
allergies
Respiratory Problems
asthma
Allergies or Autoimmune Problems
Ear, Nose & Throat Problems
sinus
Heart/Cardiovascular problems
fever
Constitutional Problems
diabetes
Endocrine Problems
heart burn / acid reflux
Gastrointestinal Problems
pain
Genitourinary Problems
HIV+
Infectious Problems
Skin/dermatologic Problems
rashes
Musculoskeletal Problems
osteoarthritis
Psychiatric Problems
depression
headaches
Neurologic Problems
high blood pressure
Glaucoma
Any past trauma to the eye?      
Strabismus (eye turn)
Primary care physician's name
What type of glasses do you wear currently?
No
Yes
Your Appointment Date:
Last Name
Communication Preference
Relation to responsible party
Employment Status:
Medical Insurance Phone
Insured's Full Name
Group Number
Ethnicity*
Please tell us the main reason for your visit:
emphysema
ear infections
weight gain or loss
thyroid
IBS
blood in urine
hepatitis
rheumatoid arthritis
dryness
joint pain
anxiety
numbness
high cholesterol
Diabetic retinopathy
Macular degeneration
Are you seriously considering LASIK within the next six months?
Your Appointment Time:
Nick Name
City, State and Zip Code
Occupation
Whom may we thank for referring you to us?
If you have no vision plan, we offer
6 or 12-month no-interest financing through CareCredit Patient Payment Plans.  Just visit www.carecredit.com or click the link above to get pre-authorized before your appointment or we can get you authorized in the office by filling out a short form. Call our patient care coordinator and she will walk you through the steps to activate your payment plan.
Vision Plan
OR
lupus
COPD
hearing loss
bradycardia
fatigue
kidney
vomiting
discomfort
tuberculosis
eczema
swelling
bipolar
weakness
Non-Eye related surgery:
Please list any medications you take:  (Include eye medications)
Please list any drug allergies and/or allergies to products such as latex that you may have:
Do you currently have, or been diagnosed with any of the following conditions:  (PLEASE CHECK)          No
Cataracts
Dry eye syndrome
Do you have any special hobbies or activities you participate in?
Do you have FAMILY HISTORY of any of the following:  (PLEASE CHECK)      NO
Retinal detachments
Are you planning to purchase new glasses when you come in for your examination?
Preferred Pharmacy (store name & approximate location, i.e. cross roads)
What type of contact lenses do you wear?
Social Security Number
ID Number
Relationship to Insuredd
Height*
tachycardia
Cancer
Is there anything else you would like us to know or you would like to enter such as medical problems, eye issues or other concerns that are not listed above?
Home Phone
Work Phone
Employer
Weight*
Strabismus (eye turn)
Amblyopia (lazy eye)
Have you had any eye surgery such as cataract surgery, laser surgery or eye muscle surgery?  Please list procedure and year performed.
What disinfecting solution do you use?
Texting okay for appointment confirmations?
Person's name who referred you to us?
Insured's Date of Birth
congestive failure
AUTHORIZATION FORM

CLICK THE LINK BELOW TO DOWNLOAD, PRINT AND SIGN OUR PAYMENT AND INSURANCE AUTHORIZATION FORM. PLEASE BRING THIS FORM WITH YOU TO THE OFFICE ON THE DAY OF YOUR APPOINTMENT.  YOU MAY ALSO FAX IT TO OUR OFFICE AT 941-756-1925.   
                                                                                                           
AUTHORIZATION FORM
Cell Phone
Group Number
The Vision Source 20/20 Savings Plan is a discount plan available to you at absolutely no charge. Once you sign up, you will receive an ID card. When you present your ID card at the time of purchase you will be eligible for discounts on examinations, eyeglasses, contact lenses and even medical office visits if you do not have a valid medical or health insurance plan.  Also, you can use the Vision Source 20/20 Savings Plan at any Vision Source location in the nation.
Vision Plan Phone
PLEASE BRING YOUR INSURANCE CARDS WITH YOU SO THAT WE MAY MAKE A COPY. 

PAYMENT IS DUE WHEN SERVICES ARE RENDERED UNLESS PREVIOUS ARRANGEMENTS ARE MADE.
Insured's Full Name
*Lakewood Family Eye Care is required by the Florida Agency for Health Care Administration to report the following information to maintain state accreditation. Lakewood Family Eye Care maintains strict privacy of your medical records and related personal information as required by the Federal HIPAA Privacy Rule. We may also use and/or disclose your information to authorized agencies in accordance with federal and state laws.
How often do you sleep in your lenses?
Attention-Patients who wish to try contact lenses or who already wear them:  Please  read our Understanding Contact Lens Professional Fees page.
(Input masked)
(Please print and sign)
Driving 
Computer 
Read 
Golf
Tennis
Walk
Boating 
Fishing
Crafts
Volunteer
Hunting
A well-patient routine vision exam is done yearly to check for vision changes, screen for eye disease and to make sure your eyeglass and contact
lens prescription is up to date.  Examples of complaints that require a routine exam are blurred vision or I need new glasses.  This includes a
refraction to measure your vision, a dilated retinal examination and a variety of other tests. (No topical or oral medical prescriptions will be written)
This type of examination will be billed to your vision plan.
(No medical problems will be addressed with this type of an exam)
This type of eye examination will be billed to your medical insurance carrier.
(We can still check you for glasses and contact lenses if needed)
A medical eye exam is a comprehensive examination which includes checking you for glasses or contact lenses but the reason for the visit is more
medical in nature.  Examples of complaints that require a medical eye exam may include pain, discharge, itchiness, dryness, light
sensitivity, inflammation, red eyes, double vision, flashes, floaters, lumps or bumps. Also, having chronic conditions such as diabetes,
cataracts, glaucoma, macular degeneration, eye turn or dry eye syndrome require more responsibility and require a higher level of
medical decision making by the doctor.
My examination today is considered MEDICAL in nature.  I authorize Lakewood Family Eye Care to bill my MEDICAL INSURANCE (i.e., AETNA, BCBS, MEDICARE, etc.) I have a sign, symptom, chronic eye condition (i.e., diabetes) that I wish the doctor to evaluate during my eye examination.  I understand that I will be responsible for applicable specialist co-pays, co-insurance, deductibles, refraction and digital retinal imaging fees.
My examination today is considered ROUTINE in nature.  I authorize Lakewood Family Eye Care to bill my VISION PLAN (i.e., VSP, Eyemed.) I understand that my vision plan DOES NOT cover evaluations for medical eye problemss or disease.  I understand that if a medical eye problem is discovered I may need further evaluation or testing which can be billed to my medical plan on a different day. I understand that I will be responsible for applicable co-pays, co-insurance and digital retinal imaging fees.
Please read the following to determine if your eye examination will be considered MEDICAL or ROUTINE.
We perform DIGITAL RETINAL IMAGING as a part of our examination.
Digital retinal imaging (DRI) is a procedure consisting of taking a digital image of the inside of the eyeball with a state of the art digital retinal
fundus instrument.  These are not X-rays and there are no side effects.  This advanced diagnostic test is invaluable in detecting eye disease such
as diabetes, hypertension, glaucoma, macular degeneration or retinal tumors and allows us to keep the images as a permanent part of
your record.  Insurance companies do not cover routine digital retinal imaging at this time.  DRI is done in addition to dilating the eye. The fee for
the DRI test is $19.00. (This amount will be added to your co-pay at the time of your visit.)
PLEASE CHOOSE ONE OF THE FOLLOWING:
WELCOME
All information will be kept confidential and will be helpful in providing the very best eye care to you. Your information is secured by SSL data encryption, password protected and only accessed from the doctor and our clinical staff members. Your personal data is completely erased and is no longer accessible from our patient registration system once our office staff has obtained your information. Our office adheres strictly to HIPAA procedures.
A MEMBER OF
LAKEWOOD FAMILY EYE CARE
Call (941) 739-5959 today!
Vision Source is North America's Premier Network of Private Practice Optometrists.
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