WELCOME TO COPPELL VISION CENTER

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1 WELCOME TO COPPELL VISION CENTER Please Print Name Address Sex: Male Female City/State/Zip Age Home Phone of Birth Alternate Phone SSN# Profession Employed By Responsible Party Address and Phone Number (if different) Name of vision insurance plan (if applicable) Employed By Member Name Member I.D. # of last eye exam Do you wear: Glasses Contacts Both Contact type/brand/powers? If you wear contact lenses, are you satisfied with: Vision? Yes No Comfort? Yes No Wearing Time? Yes No Please list your current medications: Are you allergic to any medications? Yes No If yes, please list: Do you work with a computer? Yes No If yes, how many hours/day? Do you use special glasses for your computer work? Yes No Are you interested in refractive surgery (i.e. LASIK)? Yes No Would you like to discuss this topic? Yes No Do you have any of the following conditions? (Please circle all that apply to you) Previous Eye Injury Previous Eye Surgery Glaucoma Cataract Retinal Detachment Floaters Flashes Eye Turn Amblyopia Double Vision Severe Headaches Diabetes High Blood Pressure Heart Disease Sleep Apnea Other Is there any family history of the following? (Please circle all that apply) Glaucoma Cataracts Macular Degeneration Blindness Amblyopia Other serious eye disorders (please describe): What is the main reason for your visit? How did you hear about our office? Did anyone refer you to our office? Yes No If yes, name:

2 At Coppell Vision Center we pride ourselves on providing our patients with the best possible standard of care. Because of this we now perform the optomap Retinal Exam with our patients. This non-invasive procedure allows your doctor to see a much broader and more detailed view of the retina than is possible with conventional methods. When reviewed, the scan becomes a permanent part of your medical file, enabling your doctor to make important comparisons should potential vision threatening conditions show themselves at a future examination. Dr. Pels and Dr. Elston strongly believe that the optomap Retinal Exam is an essential part of your comprehensive eye exam and prescribes it for all patients once per year. This scanning technology allows us to view the inside of your eye without the use of dilation drops. We may be able to detect early signs of glaucoma, diabetic retinopathy, retinal detachments, macular degeneration, hypertension, and many other serious vision and health concerns. Takes less than one second to take picture of up to 80% of your retina Digital record of the internal structure of your eye to compare at future visits No blurring or light sensitivity following exam You can see the inside of your own eye A dilated exam can be performed at your exam, but please note that it will have an effect on your vision for 4-6 hours (blur and light sensitivity). Although the dilation is a very thorough way to look at the retina, there is no permanent record without photo documentation. The doctor cannot fully assess the health of your eyes without the optomap or a dilated exam. Our office is charged for each patient that has pictures taken so we charge an additional $35 per patient for this service. Unfortunately, the optomap is NOT currently covered by insurance plans. Please take the optomap photos of my eyes today ($35 additional charge) I decline the photos today and request a dilated exam (no additional charges). I decline both photos and dilation of my eyes today. I understand that the doctors are not able to examine as much of my eyes by declining these tests and that I am willing to accept this risk. Patient Signature

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5 COPPELL VISION CENTER Laura Pels, O.D. Sandra Elston, O.D. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By my signature below, I acknowledge that I have received or was offered a copy of Coppell Vision Center s Notice of Privacy Practices. I also understand that any unpaid charges not covered by insurance are my financial responsibility. I hereby authorize Coppell Vision Center to release all information needed to determine these benefits and thereby secure payment. If needed, I authorize the use of this signature on all insurance claim submissions. Patient Signature Who may we give information to regarding your condition, treatment, diagnosis, or financial responsibility? Spouse Son/Daughter Parent Other Please list anyone who should not have this information May we contact you at: Home Number? YES NO May we leave a message? YES NO Cell Number? YES NO May we leave a message? YES NO Work Number? YES NO May we leave a message? YES NO

19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405

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