Your eye exam includes much more than just checking your vision. It is of the utmost importance to assure that your eyes are healthy and disease free. In order for Dr. Taylor and/or Dr. Hall to examine your eyes adequately it may be necessary to have additional testing performed during the exam or at another scheduled appointment. Dr. Taylor and/or Dr. Hall will discuss the nature and necessity of these tests with you before performing them. These tests may incur additional fees which may not be covered under your vision insurance, but may be covered under your medical insurance. Therefore, even if you do not currently have vision insurance, please fill out the information below concerning your medical insurance and bring your insurance card to the front desk. If you have any questions or concerns, please feel free to speak with a member of our staff.
PATIENT COMMUNICATION OPT-IN ACKNOWLEDGEMENT
How would you like best to be contacted when your ordered items have arrived or for appointment reminders?
Name of eye doctor or location:
Interested in learning more about LASIK or other corrective surgical procedures?
Are you the primary insured?
(if yes, skip section below)
Please check any problems below, as best you can, that you are currently experiencing:
Please mark any of the following symptoms noticed after extended computer/device usage:
Do you currently wear glasses?
If YES, do you wear them:
What type of lenses do you wear?
What do you like about your current glasses?
What would you change about your current glasses?
Do you currently wear contact lenses?
Please be aware that there is a contact lens fitting fee that may or may not be covered by your insurance. This fitting, by law, has to be updated every 12 months in order to have an active contact lens Rx and be able to order contact lenses.
If you are a current contact lens wearer, please answer the following questions:
What brand or type of contact lenses do you wear?
How old are your current lenses?
How often do you replace your lenses?
What is your normal wear schedule?
Are you having any problems with your current contact lenses?
What brand of solution do you soak and clean your lenses with?
Do your back-up glasses have your current Rx?
If you DO NOT wear contact lenses, please mark any of the following statements that apply to you:
Name of Primary Care Provider (PCP):
How long have you been treated for any of the above conditions?
Please describe any major surgeries and the year performed (including any eye surgeries/procedures):
If YES, how do you smoke and how often?
If you are diabetic: How often do you check your glucose levels?
CURRENT MEDICATIONS Over-the-Counter AND Prescription (Add dosage and frequency):
Clicking 'Submit' below will privately and securely send your information to us in a HIPPA compliant manner.
Choosing Text/Email will ensure a quicker response time. Phone calls are made at the end of the day.