Lake Travis Eye and Laser Center, PA Current Patient Form

Lake Travis Eye and Laser Center, PA
Kyle M. Rhodes, M.D. Tommy Q. Dang, M.D.

In order to update your medical history, please complete the following:
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for upcoming visit:
Any known ocular issues you may have?
Are you interested in Refractive surgery (LASIK, Kamra Inlay, Clear Lens Exchange) for yourself?

YesNo
Primary Care Doctor:
Preferred Pharmacy:

List all medications and eye drops that you are currently taking, both prescribed and over the counter (name, dose & frequency required):

	Name of medication	Dosage	Frequency
1.
2.
3.
4.
5.

List any known drug allergies and any reaction (hives, rash, swelling, etc.):
List all surgeries (including eye surgeries) that have occurred since your last visit:

	Yes	No	Not applicable
Pneumonia Shot
Flu Shot
Are you pregnant?
Are you nursing?
Are you on birth control?

Retinal Screening

A retinal screening is an integral part of a thorough comprehensive eye examination. This allows early detection of pathology such as diseases of the optic nerve, disease of the retina, vascular changes, retinal tumors, etc. This is usually done through a dilated pupil. New technology now allows an image of the retina to be captured through an undilated pupil with the Optos camera. It only takes 1-2 minutes to capture the images which will be available for review during your exam and in the future. Please note that we still ask patients with specific symptoms or diagnoses to dilate, in order to view the retina beyond the 80% captured with the Optos (ie. Diabetic Eye Exam, Macular Degeneration, Glaucoma, Flashes & Floaters, Cataract PreOps).

Please understand that this service is not covered under insurance as a screening examination. Our office charges a $40.00 fee at the time of your visit for the Optos Fundus Photography. If the doctor request this image due to specific diagnosis, then we will bill insurance and not collect the fee at the time of your visit until we receive notice of coverage from your insurance.
Optos image and dilation options:

I elect to have the Optos image of my retina for $40.00.I decline the Optos image and am choosing to be dilated.I decline both the Optos and dilation. I elect not to have a thorough comprehensive eye examination today.
Digital Signature Authorization:

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
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