Should you need assistance in completing this form, please ask one of our caring staff.
At Today’s Vision, we are dedicated to providing you with the most comprehensive contact lens care possible. To ensure your long-term success with contacts, we will: Evaluate your visual acuity and assess the fit of your current contact lenses, microscopically evaluate the health and scan the topography of the front surface of your eyes and review the results of this evaluation and discuss available contact lens options.
* The Contact Lens Evaluation is NOT considered part of the Comprehensive Eye Exam; thus there is a separate contact lens fitting fee. Please ask us if you have any questions.
I authorize Today’s Vision to release any information including the diagnosis and records of any treatment rendered to me or my dependent during such period of eye care to any third party payers and/or health care practitioners. I authorize and request my insurance company to pay directly to Today’s Vision any benefits otherwise payable to me. I understand that in the event my insurance does not fully pay for services and/or materials rendered to me, I agree to be responsible for payment of all balances on my or my dependent’s behalf.
In order for our clinic to file your medical and vision insurance appropriately, we must have a copy of your current medical insurance card and Driver’s License and must have the name of your vision insurance plan. If the comprehensive eye exam is covered by the medical and vision plans, our policy is to bill the medical insurance first.
I certify that I have read and understand the above information to the best of my knowledge. I understand that all fees for professional services shall be paid at the time of service and are NON-REFUNDABLE. I am also aware that prescription eyeglasses are a custom order. Therefore, any cancellation will result in a 25% service charge on the order.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES (‘NPP’)
I acknowledge that I have received and/or read a copy of Today’s Vision’s Notice of Privacy Practices.
We pride ourselves on remaining at the cutting edge of technology in diagnostic testing. We are committed to the early detection and prevention of eye diseases that can lead to serious progression and vision loss. We strongly recommend that all of our patients receive these Wellness Tests as part of his/her comprehensive eye examination:
EYESCREEN PHOTOGRAPHY: The OPTOMAPis a NEW State-of-the-art technology that gives similar results to eye drops and dilation. It consists of a high resolution (10.1megapixels) photograph that digitally maps the back of the retina within seconds. This is a critical component of the eye exam that enables the doctor to detect early signs and changes of ocular disease such as diabetes, hypertension, glaucoma, cataracts, macular degeneration, and certain types of tumors. It also gives a baseline image to permanently add to your medical file and allows the doctor to perform a serial analysis of any changes over time. There is a $39 co-pay for this retinal exam (Note: Some medical insurances may cover this test).
PUPIL DILATION: This test checks for the same medical conditions as above. Dilating drops enlarge the size of the pupil (the central black spot of the eye) in usually 30 minutes. The side effects are light sensitivity and blurred near vision which may last up to 8 hours. An unlikely side effect from dilation is a sharp sudden rise in the pressure of the eyes that may create an ocular emergency. You will usually be able to drive home with the aid of dark glasses.
VISUAL FIELD ANALYSIS: This highly computerized instrument provides an analysis of your peripheral fields of vision. By detecting abnormal blind spots, a visual field screening can assist the doctor in the early detection of glaucoma, retinal abnormalities, neurological diseases, and possible causes of headaches.
ANTIOXIDANT SCAN: The BIOPHOTONIC SCANNER is a groundbreaking device that measures the antioxidant levels in your skin. This is directly linked to the disease fighting antioxidant levels in your eye and other tissues of the body. Studies have shown that certain vitamins and carotenoid antioxidants decrease the risk of dry eyes, macular degeneration, glaucoma and cataracts (along with cancer, diabetes, heart disease, stroke, and many other systemic diseases). We can now easily measure and track your storage of these vital nutrients and we can then discuss and recommend general nutrition and ways to improve your carotenoid levels. The doctors use the BioPhotonic Scanner to monitor their personal health and highly recommend the scanner for every patient. The scanner is non-invasive and only takes 30 seconds. There is a $20 co-pay for this exam (Note: this is not covered by insurance).
Please choose the following tests: