Dr. Savannah Lamb & Associates
PLEASE FILL OUT THIS FORM PRIOR TO YOUR EYE EXAM APPOINTMENT
Email address *
Appointment Date *
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Name *
Phone Number *
Date of Birth *
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Gender *
Address *
City *
State *
ZIP *
Vision Insurance Company and ID #:
Medical Insurance Company and ID # :
What is your occupation?
Do you smoke? *
Do you drink alcohol excessively? *
Do you use illegal drugs? *
When was your last eye exam?
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Last medical exam?
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Are you pregnant or nursing? *
Height
Weight
Who is your primary care doctor?
Diabetic? *
If diabetic, for how many years? What was the # of your last A1C reading and when?
Drug Allergies (if no allergies, please write "none")
Medications (if you do not take any medications, please write "none") *
Surgeries, hospitalizations, stroke, heart attack?
Eye Disease/Eye Surgeries?
Does anyone in your family have Macular Degeneration or Glaucoma?
Do you want a Contact Lens Prescription today? Yes or no and Current Brand:
SYMPTOMS: EYES
CARDIOVASCULAR
ENDOCRINE
EAR/NOSE/THROAT
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LYMPHATIC/HEMATOLOGICAL
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GASTROINTESTINAL
GENITOURINARY
MUSCULAR/SKELETAL
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NEUROLOGICAL
PSYCHOLOGICAL
RESPIRATORY
SKIN/IMMUNE DISEASE
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OTHER
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RETINAL PHOTOGRAPHY (INSURANCE PATIENTS ONLY): If paying with insurance, your retinal exam will be an additional $30 COPAY. Retinal photography takes place of eye drop dilation, allowing you to NOT be dilated. The photos become permanent to your medical file, enabling your doctor to make important decisions for your eye health. We STRONGLY recommend that retinal photography is performed as it is an essential part of your comprehensive eye exam every year. (This service IS covered by Medicare therefore all patients using Medicare will have retinal photography performed at no additional cost.) *
CONTACT LENS FITTING (CONTACT LENS WEARERS ONLY): Wearing contact lens is a risk. If you have ANY eye pain, redness, excessive watering, discharge, cloudy or foggy vision, decrease in vision, or increased sensitivity to light, it is recommended to REMOVE your contact lenses every night for cleaning and disinfection, as well as having an appropriate pair of backup glasses. CONTACT LENS FITTINGS INCLUDE ALL NECESSARY FOLLOW-UPS WITHIN 30 DAYS. AFTER THIS PERIOD, THERE WILL BE AN ADDITIONAL FITTING FEE. *
REFRACTION (MEDICARE PATIENTS ONLY): Refraction is a test that is performed to measure your best vision possible. Medicare does not pay for the refraction. You will be responsible for the $55.00 payment of this service. If you are using medicare and also wear contact lenses you will be responsible for a $60.00 payment of this service. *
HIPAA PRIVACY: I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involve in my treatment) and/ copy of my privacy rights. I agree and understand that the professional services provided to me are NONREFUNDABLE. *
While patient safety is our priority, there is always risk of exposure. We are taking all necessary sanitation precautions to help reduce the risk of virus transmission in our office space. Please understand that by scheduling this exam, you are seeking care during a pandemic. As a practice, we are NOT responsible for the risk of exposure. If you would like to reschedule your appointment for a later date, please call us at (828) 702-2555. *
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