Established Patient Form

Acknowledgment of Pupil Dilation

I understand that the Florida Board of Optometry requires optometrists to perform a dilated exam of the retina during the patient's comprehensive exam. I understand that the optometrist recommends it to more thoroughly evaluate the internal health of my eyes.

OCT Retinal Exam

The Ocular Coherence Tomographer, also known as the OCT retinal exam, is a scanning digital image of the retina, macula, and optic nerve. It allows the Doctor to better diagnose, treat, and follow changes to the retina over time. The OCT Retinal Exam is a "non-covered service" with most vision insurance plans, meaning the patient would be responsible for the charges. The Doctor highly recommends it for all patients once a year. The fee for the OCT is $45.00

***PLEASE NOTE: Payment Is expected at the time of service***

I certify that the information I provided is correct. I authorize the release of medical information necessary to process insurance claims to Medicare or any other insurance company. I authorize payment of medical payments to lnFocus Family Eyecare for any services rendered to me by any doctors of lnFocus Family Eyecare.

I understand that my insurance is a contract between my insurer and myself. I am responsible for understanding the terms of my policy, including deductibles, co-pays, co-insurance and referrals. I am responsible for obtaining any required referrals, and in absence of such, I will be held responsible for the cost of services provided.

I acknowledge that I received a copy of lnFocus Family Eyecare's Notice of Privacy Practices (HIPAA).

Contact Lens Prescription Signed Acknowledgment Form

The Center for Disease Control and Prevention (CDC) makes clear, "Contact lenses can provide many benefits, but they are not risk-free. Especially if contact lens wearers don't practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment."

The CDC recommends the following for contact lens wearers:

• Schedule a visit with your eye doctor at least once a year.

• Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision.

• Understand that eye infections that go untreated can lead to eye damage or even blindness.

• The Food and Drug Administration (FDA) indicates:

• "To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It's safer to be re-checked by your eye care professional."

• Symptoms of Eye infection include:

• Irritated, red eyes

• Worsening pain in or around the eyes-even after contact lens removal

• Light Sensitivity

• Sudden blurry vision

• Unusually watery eyes or discharge

Sign below to acknowledge and consent that you will be provided with an electronic copy of your contact lens prescription at the completion of your contact lens fitting. (If you do not wear contact lenses your signature is still required to proceed.)