EYEZ10 Patient Packet

Medical History Questionnaire
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Last Eye Exam
With Doctor
Primary Care Physician
Physician's Phone Number
Please enter a valid phone number.
If applicable - Endocrinologist
Clinic / Phone Number
Please enter a valid phone number.
If applicable - Retina Doctor
Clinic / Phone Number
Please enter a valid phone number.
Pharmacy
Pharmacy Phone Number
Please enter a valid phone number.
Do you wear glasses?

YesNo
Do you wear contacts?

YesNo
If YES

Soft lensRGPSpecialty Lens

Ocular History - Check which eye affected

	Left	Right	Both	Details
Dry Eyes
Herpes Simplex / Zoster (Shingles)
Retinal Tear / Detachment
Diabetic Retinopathy
Macular Degeneration
Glaucoma
Keratoconus
Fuch's / Corneal Dystrophy
Cataracts
Amblyopia / Lazy Eye
Color Blindness
Uvitis / Iritis
Retinitis Pigmentosa
Eye Injury (State in Details column)

Other Ocular History not listed above

Past Ocular Surgery

	Eye(s)	Date (if known)	Surgeon and/or other details
LASIK / PRK
RK / AK
Cataract Surgery
Yag Capsulotomy
Corneal Transplant
Muscle surgery
Retinal surgery (please specify in details)
Glaucoma
Eyelid surgery
Other (please specify in details)

Please list all major conditions/diseases/injuries (e.g. Diabetes, hypertensions, high cholesterol, concussions, anxiety)
Please list all previous surgical procedures (e.g. cardiac ablation, hip/knee replacement, skin cancer excision)
Are you taking any medications - prescribed or over-the-counter?

YesNo

Allergies to Medications - Check all that apply

None / NKDAAmoxicillinBactrimBeta-BlockersCiprofloxacinDoxycyclineErythromycinFluoresceinIodine / BetadineKeflexLatexPenicillinSulfaTobramycin
Others - Please List:
Do you drink alcohol?

YesNo
If yes, how much: Rare, Social, # drinks per week
Do you smoke?

YesNoFormer Smoker
Former smoker - year quit:
Packs per day:
Are you in an Assisted Living Facility?

YesNo
Name of Facility?
Are you on Hospice?

YesNo
Have you fallen down in the past year?

YesNo
Are you pregnant or breast feeding?

YesNo

Family Medical History

	NO	YES	Please list affected family member(s)
If Adopted/Unknown, check YES
Retinal tear/detachment
Macular Degeneration
Glaucoma
Keratoconus
Corneal Dystrophy
Amblyopia/Lazy Eye
Color Blindness
Cataracts
Lupus/Sjogren's syndrome
Multiple Sclerosis
Hypertension
High cholesterol
Heart disease
Diabetes
Thyroid disease
Cancer
Arthritis/Rheumatism
Asthma/COPD

Other Family Medical History not listed above
Are you currently experiencing any issues with the following:
HENT

SinusSeasonal AllergyHearing LossDry mouth
Allergy / Immunology

Seasonal allergiesSjogren'sLupusRAMultiple Sclerosis
Cardiovascular

HypertensionHeart diseaseHigh cholesterolHeart attackAFib
Constitutional

Weight gainWeight lossFeverChillsFatigue
Endocrine

Heat/Cold intoleranceDry skinPituitary issues
Diabetes

Type IType IINon-InsulinInsulin
Thyroid Disease

HypothyroidHyperthyroid / Graves
Gastrointestinal

IBSConstipationGERDDiarrhea
Genitourinary

Urinary urgencyProstate issuesIncontinenceKidney Disease / Failure
Hematology/Oncology

Bruise easilyAnemiaHIV/AIDS
Hepatitis

ABC
Cancer - if yes, please check treatment(s) and list type

ChemoRadiationType:
Integumentary (Skin)

RosaceaPsoriasisEczemaRash
Musculoskeletal

Marfan's syndromeArthritisCarpal tunnelFibromyalgia
Respiratory

Shortness of BreathAsthmaCOPD
Sleep Apnea

NoYes, without CPAPYes, with CPAP
Neurologic

ConcussionsHeadacheMigraineSeizuresStrokeMemory issuesAlzheimer'sNeuropathy
Psychiatric

ADDADHDAnxietyDepressionBipolar
Financial Responsibility Notice
Patient's Name*

First NameMiddle NameLast Name
Account Number (Office Use)

The purpose of this form is to help you make an informed choice about your visit today.
Before you make a decision about your options, you should read this entire notice carefully.

Medical and/or Vision Insurance plans may not cover the following services:

Items or Services:	Cost:
Dry Eye Testing (Checks for tear osmolarity and dry eye syndrome)	$250+
Refractions (Tracks changes in vision/glasses prescription)	$60
Contact Lens Renewal (Updated prescription for established patients)*	$85
Contact Lens Prescriptions (For new patients or with new kind of lens)* *Contact Lenses may be purchased with our office at patient request. It is patient choice for most lenses if would like to purchase with our office. Some lenses require purchase through our office. when requested by patient Cost of lenses depends on the brand	Starts $125+
Deductible (100% of the visit will be collected at time of service)	May Vary

You will be responsible for the 100% of all fees for each procedure at the time of service.
*Prices are subject to change, but you will be notified of any changes. *

These tests may not apply to you, but these tests may be recommended by your doctor today or at a future visit. If you have any questions, please ask the front desk.

Please note: If you have an insurance we do not take and it does not have out of network benefits, you are financially responsible for your visit. Payment must be made in full.

I have read and understand the above statement and agree to pay for all services, and understand that if my insurance pays for any of these services, I will be reimbursed.

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.
Signature*

Clear
Date

MonthDayYear
Date
PATIENT CONSENT FOR NON-SECURE E-MAILS
Patient's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Patient's Email Address
example@example.com
If you prefer to communicate by Email or would like us to send you future Emails regarding your account (such as itemized receipts, medication instructions, or glasses prescriptions,) please read the following carefully:
- Email is best suited for routine matters and non-urgent questions. You should not send us Emails for urgent or emergency situations. Your provider/provider office will attempt to read and respond promptly to email, but cannot guarantee that email will be read and responded to within any particular period of time. Time sensitive issues should be taken care of by telephone. Please call 512-427-1100 for these matters. If it is an emergency, please call 9-1-1.
- Email is not secure. While we try to protect our email. ECOA cannot guarantee the security and confidentiality of any email you receive from us, as the email is sent across the internet and could be intercepted and read.
- Any email sent or received may be filed on your electronic health record depending on the nature of the email and can become a permanent part of your health record. Emails can be used as evidence in court.
- Your provider may forward your email to other staff members as necessary for response. However, your email will not be forward outside other ECOA team without your authorization or consent.
- You are responsible for protecting your password or other means of access o your email.
Patient Acknowledgment, Agreement, and Release:
- I have read and fully understand this consent and release form.
- I understand the risk involved using email and I accept those risks.
- I understand the limits set out for using email with ECOA and I agree to follow these limits.
- If I no longer wish to receive email, I will notify ECOA.
- I agree that ECOA (and all their physicians, staff, agents, and officers) shall not be responsible for any privacy break or other damages as a result of my choice to receive emails from ECOA and I release ECOA (and all their physicians, staff, agents, and offices) from any liability relating to communicating with me by email.
OR check the below if you do not wish to receive email and sign below.

I do not wish to receive emails
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.
Patient Signature*

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
HIPAA Release

Keeping our patient’s information private is important to us and by default we will only disclose information related to that patient’s Billing Account and Medical Conditions to the patient or legal guardian.

If you would like to add additional contacts (other than patient or legal guardian) that Eye Clinic of Austin is allowed to disclose this type if information to, please complete the fields below and select the appropriate checkboxes based on your approval for each person you list.

Additional Contacts

	Contact Name	Relationship to Patient	Contact Phone Number	Information to be released
1.
2.

Information from persons not listed on this form will require my specific written authorization prior to the disclosure of any health information.
Check below for self only (if you do not wish to list anyone above) then sign & date below.

SELF ONLY
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.
Signature*

Clear
Name

First NameLast Name
Date

MonthDayYear
Date
Periodic eye evaluations are crucial as many eye problems can develop without any warning signs. It’s unfortunate that many advanced diagnostic tests are not covered by health insurance.
However, we can perform these diagnostic evaluations at a discounted price.

New Patient Advanced Diagnostic Testing

Refraction $75
OCT-M- Tomography of Optic nerve $150
OCT-R- Tomography of Retina $175
Pentacam- Corneal Topography $100
OPTOS $100

Total: $600

Discounted Fee for Service ($420)

Total Amount Due: $180

I understand that these fees are not covered by insurance; it is out of pocket and will not be billed to insurance. I am aware that payment is collected before services are rendered.
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.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

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