Home ○ Forms Forms New Patient Form – Optic Gallery Summerlin Please fill out the entire New Patient Form. It will be sent to our office upon submission. Step 1 of 3 – New Patient Form – Optic Gallery Summerlin 33% Today's Date* MM slash DD slash YYYY First Visit?* Yes No Name* First Last Sex* Female Male Age* Date of Birth* MM slash DD slash YYYY Preferred Name* Patient's Social Security Number* Email* If married, Spouses Name First Last Spouse's Social Security Number Spouse's Date of Birth MM slash DD slash YYYY If Child, Parent's Name First Last Parent's Social Security Number Parent's Date of Birth MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Home Phone*Mobile Phone*Business PhonePlace of Employment/School Occupation Does your work require special vision needs? Yes No If "Yes", please explainPrimary Insurance Primary Insurance # Vision Care Plan Date of Last Exam* MM slash DD slash YYYY Where Doctor Do you wear contact lenses?* Yes No Sometimes Type of Contacts? Are you interested in wearing contacts?* Yes No Reason for Today's Visit?* List Activities/Hobbies* How were you referred to Optic Gallery Summerlin?* Medical HistoryMedical Doctor Date of Last Visit* MM slash DD slash YYYY Have you ever had any of the following medical conditions?* I Have NO Medical Conditions Heart Diabetes High Blood Presure Thyroid Problems Headaches Asthma Lung Disease Cancer Kidney Disease Sinus Problems Allergies Major Illness Pregnant/Nursing Surgery Other If you indicated "Other", please explain*Do you* Smoke Drink Use Drugs I DO NOT smoke, drink or use drugs Medications & AllergiesMEDICATIONS*Please list any you are taking or have taken in the pastALLERGIES*Please list any allergies you have or have had in the pastDo you have a Family History of* I Have NO Family History of Medical Conditions Diabetes Heart Disease Cancer Lung Disease High Blood Presure Other Ocular HistoryDo you have* I have NO Ocular Conditions Glaucoma Cataracts Macular Degeneration Blindness Blurred Vison Double Vision Flashes Floaters Eye Itching Eye Watering Eye Redness Eye Fatique Color Blindness Eye Turn or Lazy Eye Eye Surgery, (PRK. Lasik, etc.) Other Eye Disease If you had Eye Surgery, please explainIf you checked "Other Eye Disease", please explain Does anyone in your family have?* I have NO Family History of Ocular Conditions Glaucoma Blindness Macular Degeneration Eye Disease Other If you checked "Other" under Ocular Conditions, please explainPatient Information Acknowledgement* I agree and understand the Patient Information Acknowledgement In the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, I authorize Optic Gallery, Dr. Jordan, Dr. Radtke, or any of their associates to release and/or request these records. If applicable, I request that payment of authorized Medicare or other insurance be made either to me or on my behalf to Optic Gallery, Dr. Jordan, Dr. Radtke or any of their associates for any services rendered to me. I authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies. I understand that should my financial account become delinquent, it will be sent to collections where I will be responsible for any collections fees, attorney fees, and court costs. I UNDERSTAND I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY. It is the policy of this office to require: 1) Payment in full or at least one-half before the order can be placed. 3) All orders are final when placed. 2) The balance of the fee must be paid at the time the order is dispensed.SIGNATURE (Parent or Guardian)* Today's Date* MM slash DD slash YYYY Patient's Name* First Last Today's Date* MM slash DD slash YYYY Acknowledgement Notice of Privacy PracticesSigning in this section signifies that you have received a copy of our Notice of Privacy Practices In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for these services, and to conduct healthcare operations involving our offices. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. Record Retention Policy We are informing you that our office will keep your records for 5 years from the date of this examination. If signing for a minor, please be aware that our office will only keep your child’s records for 5 years from the date of this examinationConsent* I agree to and understand the “Acknowledgement Notice of Privacy PracticesSignature (Parent or Guardian) Signature Date* MM slash DD slash YYYY iWellnessExam & Digital Retinal PhotographyThe iWellnessExam is a quick, non-invasive scan that allows our doctors to see beneath the surface of your retina. This unique technology combined with digital retinal photos can help our doctors detect vision threatening conditions and systemic diseases in their very early stages, when they are most treatable. Our doctors recommend these tests as a routine part of the comprehensive eye exam for all of our patients. They are a great alternative if you would prefer not have your eyes dilated at this visit. The iWellnessExam and digital retinal photography are especially important if you or your family have a history of diabetes, high blood pressure, high cholesterol, headaches, cataracts, glaucoma, macular degeneration, or other eye conditions. These conditions can be monitored closer and more accurately with these tests. The cost of these procedures is $49. It is not routinely covered by insurance. Please ask our staff if you have any questions. Please select one of the options below, indicating your choice for the iWellnessExam and digital retinal photography:Options* I wish to have the iWellnessExam and retinal photography performed today I have additional questions about the iWellnessExam and retinal photography Consent* I understand and agree to the iWellnessExam & Digital Retinal Photography StatementIn the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, I authorize Optic Gallery, Dr. Jordan, Dr. Radtke, or any of their associates to release and/or request these records. If applicable, I request that payment of authorized Medicare or other insurance be made either to me or on my behalf to Optic Gallery, Dr. Jordan, Dr. Radtke or any of their associates for any services rendered to me. I authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies. I understand that should my financial account become delinquent, it will be sent to collections where I will be responsible for any collections fees, attorney fees, and court costs. I UNDERSTAND I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY. It is the policy of this office to require: 1) Payment in full or at least one-half before the order can be placed. 3) All orders are final when placed. 2) The balance of the fee must be paid at the time the order is dispensed. Consent of Agreement* I understand and agree to the Agreement stated above.SIGNATURE (Parent or Guardian)* Date of Signature* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
