Please complete this form prior to your appointment. We look forward to seeing you!

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Date of Birth
Cell Phone
Home Phone

Preferred Contact Method
Marital Status

Emergency Contact

Emergency Contact Name
Emergency Phone Number

Primary Medical Insurance

Primary Medical Insurance
Insurance Provider
Is the Primary Insurance Subscriber the same as the Patient?

Secondary Medical Insurance

Do you have secondary medical insurance?

Primary Care Physician Information

Primary Care Physician Name
Phone Number

Eye History

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Date of Last Eye Exam
Do you wear contacts?(Required)
Do you currently wear glasses?(Required)
Have you have LASIK/PRK?(Required)

Has a family member experienced, or been treated for, any of the following?

Macular Degeneration(Required)
Retinal Detachment(Required)
Lazy Eye(Required)
Crossed Eye(Required)

Your Medical History

Do you smoke?(Required)
Are you nursing or pregnant?(Required)
Thyroid Disease?(Required)
Sinus Trouble?(Required)
Blood/Lymph Disorders?(Required)
Skin Conditions?(Required)
High Blood Pressure?(Required)
Heart Disease?(Required)
High Cholesterol?(Required)
Gastrointestinal Conditions?(Required)
Kidney Disease?(Required)
Rheumatoid Arthritis?(Required)
Neurological Conditions?(Required)
Psychiatric Disorders(Required)

Refraction Policy and Financial Responsibility Agreement

Refraction Policy and Financial Responsibility Agreement Most medical insurance plans, including Medicare, do not cover a refraction (the test used to determine a glasses prescription). If you request a refraction during your office visit and receive a new prescription, there will be an additional fee, since it is not a covered service. By agreeing to these terms and conditions, I understand that if I elect to have a refraction and receive a glasses prescription, I am responsible for the refraction payment that is due at the time of my visit.
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Information Regarding Dilating Drops

Dilating drops are used to dilate or enlarge the pupils of the eye to allow the doctors at Laser Eye Surgery of Erie get a better view of the inside of your eye. Dilating drops blur the near vision. It does not affect the distance vision, but light sensitivity can make driving difficult afterward. It is not possible for your doctor to predict how much your vision will be affected. You may need a driver afterward. Adverse reactions, such as acute angle-closure glaucoma, may be triggered by the dilation drops. This is extremely rare and treatable with immediate medical attention. By agreeing to these terms and conditions I hereby authorize Laser Eye Surgery of Erie, to administer dilating eye drops. The eye drops are necessary to diagnose my condition.
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Notice of Privacy Practices

Our notice of privacy practice provides information about how we may use and disclose protected health information (PHI) about you. The notice contains a patient rights section describing your rights under the law. You have the right to review our notice before signing this consent. The terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of PHI about you for treatment, payment, and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosure we have already made in reliance on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
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