ࡱ>  bjbj>> qTqT!  ~~:::<K( ( ( JJJJJJJ$LOHJ:( ( ( ( J#~~J###( R~:J#( J##nQE6mH?z ^YF mJJ0KyFO O@mH#:mH( ( ( JJ#( ( ( K( ( ( ( O( ( ( ( ( ( ( ( (  * D:    Patients Name (please print) __________________________________________________ Date: ______________________________ If a child, name of parent/guardian _________________________________________ Relationship: ________________________ Spouse/Partners Name: _______________________________________Referred by: ______________________________________ Street Address______________________________________________ City_________________ State_________ Zip______________ Home Phone_______________________ Cell Phone__________________________ Work Phone ____________________________ E-Mail ____________________________________ Date of Birth ______________________ M or F SSN _____________________ Preferred Contact Method: Home Cell Work Email Text Occupation: __________________________________________Employer/School _________________________________________ Do you have difficulties with any of the following systems? Nervous system Headaches Ear/Nose/Throat Genitourinary Mental Cardiovascular Musculoskeletal Endocrine (Glands) Respiratory Skin Allergic/ Immunologic Blood/Lymph Do you have any of the following? Contacts Glasses Blurred vision Eye Injury Itchy Eyes Dry Eyes Dates and type of surgeries you have had: ________________________________________________________________________ Current medications: _____________________________________________________________________________________________ __________________________________________________________________________________________________________________ Do you have any allergies to medications or other substances? Yes __ No __ Please list ________________________________________________________________________________________________________ Do you use tobacco? Yes ____ No ____ Alcohol? Yes ____ No ____ Other substances? Yes ___ No ___ If so, please list: __________________________________________________________________________________________________ Name and phone number of primary care physician? _____________________________________________________________ Do you or any of your blood relatives have a history of any of the following? High Blood Pressure Relation: _______________ Macular Degeneration Relation: _______________ Diabetes Relation: _______________ Retinal Detachment Relation: _______________ Glaucoma Relation: _______________ Cataracts Relation: _______________ I certify that the information provided is complete and accurate to the best of my knowledge. Signature________________________________________________________________ Date _______________________________ If you are not the patient, what is your relation? ________________________________________________________________ Assignment and Release I hereby authorize my insurance benefits to be paid directly to the doctor and acknowledge that I am financially responsible for any unpaid balances. I also authorize the doctor to release any medical information necessary to provide the most beneficial and complete visual examination. Acknowledgement of Receipt and General Consent I acknowledge that I received a copy of Edward G. Bryant O.D.s Notice of Privacy Practices. I further consent to the release of my health information for purposes of treatment, payment and health care operations and as authorized or required by law under the circumstances in the Notice of Privacy Practices. Authorization to Discuss Health Information I authorize Dr. Edward Bryant to discuss my health information with the following: Name____________________________________________________Relationship______________________________ Name____________________________________________________Relationship______________________________ Signature ___________________________________________________ Date __________________________________ Do you dislike dilating eye drops? Clarity Eye Care was the first in Ithaca to offer wide field digital retinal screening, called the OptoMap Retinal Exam. This instrument captures a specialized digital image of the back of your eye in a split second and allows Dr. Bryant to view a 200-degree panorama of your retina in the examination room. It is quick, requires no drops, and is as painless as having your picture taken. Best of all, you will be able to get back to your busy life without the blurred vision and light sensitivity! Our patients come to us because they appreciate the thorough eye examination they receive. Dr. Bryant recommends that children and adults make the OptoMap part of their annual eye health examination. Insurance will not cover this advanced screening. They would prefer you to have the dilation because it is less costly than the OptoMap experience. However, the fee for the screening is only $35. Our patients agree that it is worth the investment in eye health. ___ I elect to have an OptoMap exam today. ___ I decline the OptoMap and would prefer dilation. Signature ____________________________________________________ Date _________________________________      Over ( Edward G. 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