PATIENT INFORMATION FORM

Patient’s Legal Name: D.O.B: Last Four of SS#: Sex: M /F

Address: City: State: Zip:

Home Ph: Cell Ph: E-mail:

Guardian #1 or Spouse’s Name: Cell Ph:

Guardian #2: Cell Ph:

Occupation/Grade: Employer/School:

I hereby give permission for SEG & Affiliates to leave detailed messages on my voicemail/answering machine.

I hereby give permission for SEG & Affiliates to send me emails. In order to connect your account with a family member, please list their names and ages: (parents, children, siblings)

Name: Age: Name: Age:

Name: Age: Name: Age:

How did you find out about us?

Referred by:

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

□ I was given to opportunity to read Specialty Eyecare Group’s Notice of Privacy Practices. I have either read or I declined to read. I wish to continue my care with Specialty Eyecare Group under the terms of Specialty Eyecare Group’s privacy policies.

□ I am over 18 and allow my information be shared with my family for purposes of helping me decide upon my care and/or to ensure that billing is completed properly.

Signature: Date:

FINANCIAL AGREEMENT

In signing this statement, I agree to be financially responsible for all charges. I understand that my insurance is not a substitute for payment, and it is my responsibility to pay, in advance, the deductible, the co-pay and any other balance not paid by my insurance company. I also understand that verification of my benefits is not a guarantee of payment. Most insurance policies pay only a portion of the total fees. If you have questions about your coverage, please contact your insurance company. All accounts over 60 days will receive an interest charge of 18%.

I understand that I am responsible for charges for services and products that are not covered by my insurance plan.

Signature: Date:

PATIENT FINANCIAL AGREEMENT Thank you for choosing Specialty Eyecare Group. Our mission is to enrich lives so that others can succeed to their greatest potential. We strive to do this by creating uncompromised service and happiness. In order to make sure that we are all on the same page regarding our financial relationship, we ask that you read and understand the following.

The funds necessary for your eye care treatment are ultimately your responsibility.

FOR THE PATIENTS WITH CLAIMS THAT WILL BE BILLED TO THEIR MEDICAL OR VISION INSURANCE PLAN: Your insurance is a contract between you and your insurance company and not between Specialty Eyecare Group and the insurance company. Acceptance of insurance assignment by our office does not absolve you of your responsibility for the charges for the treatment we provide to you. In most cases, we will attempt to provide you an estimate of the charges for the services that we provide in order to serve as a guideline until final insurance payment is received and your financial account has been reconciled. We can make no guarantees of the insurance payment. If your insurance does not pay for a procedure or informs us that your copayment or deductible is more than what we had initially charged at the time of your visit, you are responsible for payment in full. If there are any discrepancies, please contact your insurance company and/or your employer’s benefit department.

IF YOU HAVE A DEDUCTIBLE that has not been met, we will collect for the service that we perform on the day of the visit. Your insurance will still be billed so that the service will count towards your deductible.

Accounts that are outstanding for 60 days or more may be subject to a 18% interest charge.

In the event that your balance is sent to the collection agency, you are responsible for full payment of your account to the collection agency. You will also be responsible for any interest, late charges or fees related to collecting of your balance.

Specialty Eyecare Group charges $75 for returned checks.

A fee of $75 is charged for patients who miss or cancel an appointment without a 24-hour notice. We are in a service industry and our appointment slots are how we serve patients. If you cancel your appointment it means we don’t get to serve someone else, unless we have enough notice.

I understand and agree to take full responsibility as outlined in this financial agreement for the patient listed below. Any termination of this agreement may only be done in writing and will not apply to any action in process.

Patient Name (please print) Patient/Guardian Signature Date

HEALTH INFORMATION FORM Patient Name: ___________________________________D.O.B: Today’s Date:

Last Eye Exam On: _____________ Doctor’s Name:__________________________ Phone #:

Medications (Prescribed/OTC/Eye Drops):

Allergies (Medications):

Allergies (Seasonal/Other):_____________________________________________________________________________

Previous eye surgery (include when):______________________________________________________________

Previous eye / head trauma or injury (include when): _______________________________________________

Drinking: Yes / No Amount (Weekly): Recreational Drug Use: Yes / No Type/Amount:

Smoking Status: Never / Former /Current Amount:

Personal Health History Constitutional / ENT Cardiovascular / Respiratory Muscular / Integumentary

Developmental Disabilities Y N Hypertension Y N Arthritis: Osteo / Rheumatoid Y N Cancer Stroke / CVA Fibromyalgia Fatigue Syndrome Heart / Vascular Disease Muscular Dystrophy Pregnant / Nursing Hypocholesteremia Ankylosing Spondylitis Sinusitis Anemia Gout Dry Mouth Asthma Eczema / Psoriasis

Neurological / Psychological Bronchitis / Emphysema Rosacea Multiple Sclerosis Y N Sleep Apnea Endocrine / Immune Epilepsy Gastrointestinal / Genitourinary Herpes Simplex (cold sores) Y N Cerebral Palsy Crohn’s Disease Y N Herpes Zoster (shingles) Tumor Ulcerative Colitis Type 1 Diabetes Mellitus Migraine Acid Reflux Type 2 Diabetes Mellitus Autism Celiac Disease Thyroid Dysfunction Depression Kidney Disease Hormonal Dysfunction Attention Deficit Prostate Disease Lupus Anxiety Disorder STD Sjogren’s Syndrome Other:

Family Medical and Ocular History Condition Y N Mother Father Brother Sister Son Daughter

Hypertension Diabetes Cancer Thyroid disorder Cataract Macular Degeneration Glaucoma Other:

PERSONAL VISION/OCULAR HEALTH FORM

Patient Name: Date: ____________________

Do you wear Contact Lenses: NO. YES. (brand):_______________________________

Do you ever experience any of the following:

EYE HEALTH/COMFORT

Squinting/Eye Rubbing/Blinking Y N Headaches Y N Blurry or Double vision Red or Itchy Eyes Dry/Gritty/Uncomfortable Eyes Eye Watering

VISUAL FUNCTION Difficulty Copying from Board/Screen Y N Fatigue with reading/homework Y N Poor Handwriting, Misaligning Numbers Reversals of Letters after 1st grade Inconsistent/Poor Sporting Performance Difficulty with Reading Avoidance of Near Work Difficulty with Math Omits/Inserts/re-reads letters or words Is your child meeting their potential?

1) Frequency of Dry Eye Symptoms:

Please place an ‘X’ on the line to indicate how often, on average, your eyes feel dry and/or irritated:

2) Severity of Dry Eye Symptoms:

Please place an ‘X’ on the line to indicate how severe, on average, you feel your symptoms of dryness and/or irritation:

All the time

Very Severe

DRY EYE QUESTIONNAIRE

Name:_____________________________________ Date:______ /______ /_________ How frequently do you experience any of these symptoms? How severe are your dry eye symptoms? (Please check Frequency AND Severity)

Frequency of Dry Eye Symptoms: Please place an ‘X’ on the line to indicate how often, on average, your eyes feel dry and/or irritated: Severity of Dry Eye Symptoms: Please place an ‘X’ on the line to indicate how severe, on average, you feel your symptoms of dryness and/or irritation:

Officeuse:Score______

AllthetimeRarely

VerySevereVeryMild

Officeuse:Score______

SPECIALTY EYE BELLEVUE 225 106th AVE NE BELLEVUE, WA 98004 p.425.454.2028 SPECIALTY EYE KIRKLAND 11830 NE 128th St Suite 1 KIRKLAND, WA 98034 p.425.821.8900 SPECIALTY EYE SEATTLE 1911 4th AVE SEATTLE, WA 98101 p.206.622.4828

RECORDS RELEASE AUTHORIZATION

Patient Name: D.O.B:_____________________________

Patient/Guardian Signature: Date: _______________________________

□ Incoming Records:

Doctor or Clinic requesting records from:

Phone: Fax:___________________________________

I hereby authorize and request you to release all my medical and vision records to Specialty Eyecare Group. Please send copies of all imaging as well as diagnostic and treatment recommendations.

□ Outgoing Records:

I hereby authorize Specialty Eyecare Group to furnish my eye health and vision records to:

Doctor or Clinic requesting records to be sent to:

Address:

Phone:

Fax:

PLEASE SEND RECORDS TO EMAIL OR FAX OR ADDRESS: RECORDS@SPECIALTYEYE.COM FAX: 425.814.9782

CONTACT LENS WEAR NOTICE At Specialty Eyecare Group we strive to provide you with the clearest vision and safest contact lenses for your eyes. Washington State law requires that you receive a contact lens evaluation to minimize potentially serious complications related to contact lens wear.

Services rendered for contact lens evaluation are not included in an eye health evaluation and vision assessment. The contact lens service fees in this office reflect the expertise and time of the employees and physicians overseeing your care. These fees are outlined on below.

Contact Lens Service Fees: Fees include the assessment of current lenses for fit, power, and health.*

✓ Up to 4 follow-up appointments pertaining to the contact lens evaluation are included within the first 90 days.

✓ Additional follow-up appointments pertaining to the contact lens evaluation are $100 for the initial 90 days.

✓ In the event that a contact lens evaluation is not successful the fees for services rendered are not refundable.

If you wear standard soft lenses** the fee is one of the following:

1. Spherical: $175.00

2. Toric (for Astigmatism): $225.00

3. Multi-Focal or Spherical Mono-vision: $250.00

If you wear RGP or Custom Lenses** Initial Fit or Refit (Rx, Style or Design Change):

1. RGP or Custom Soft:$350

If you have special contact lens needs due to Keratoconus, other medical issues or complex contact lens fitting issues, there is a separate fee schedule. Please notify us if you know that you wear specialty contact lenses.

* If you are a new contact lens wearer there will be a $25 training fee. ** If your spherical prescription is +/- 8.00 or your cylindrical prescription is over –2.50 your contact lens will be considered a Custom Lens.

The cost of the contact lens supply is not included in the Service Fees.

Please Sign and Date One of the Following: I CONSENT to have a contact lens evaluation. I have read and understand the office policies and agree to the contact lens service fee schedule.

I DECLINE to have a contact lens evaluation at this time but acknowledge the office policies and contact lens service fee schedule. I understand that I will not receive a contact lens prescription at this time.

Print Name (Parent or Guardian)

Patient Name

Signature (Parent or Guardian) Date

Print Name (Parent or Guardian)

Patient Name

Signature (Parent or Guardian) Date

Patient Name Age DOB Completed by

Eye Tracking, Teaming, Focusing Never Seldom Occasionally Frequently

Visual Analysis/Discrimination Never Seldom Occasionally Frequently

Visual Figure-ground Never Seldom Occasionally Frequently

Visual Closure Never Seldom Occasionally Frequently

Visual Memory and Sequencing Never Seldom Occasionally Frequently

Visual Spatial Never Seldom Occasionally Frequently

Confusion with likenesses or minor differencesOver generalization when classifying objectsMistakes words with similar beginnings or endings

Burning, itchy, watery eyesWords run together while readingPrint moves, jiggles, shimmers while readingSkips and/or repeats lines while readingOmits small words while readingAvoids near work or reading

Difficulty keeping attention on readingPoor reader, but good understanding when read toLoses belonging / thingsForgetful / poor memoryDoes not use time well

VISUAL SYMPTOMS CHECKLIST

Eye wanders or eye crossesSquinting, eye rubbing, blinkingBlurred / Double vision

Headaches with near work

Low blink rateSensitivity to light

Written work is incompleteIgnores visual detailsPoor understanding after "looking"

Poor spelling skills

Holds reading too close

Difficulty recognizing the same word repeated on the pageTrouble writing letters or numbers & remembering them later

Difficulty completing work

Difficulty understanding concept of size, magnitude, position

Difficulty moving on from certain details with written workDifficulty knowing what is important on a pageWorks slowly compared to peers

Trouble learning the alphabet or recognizing words

Always says "I can't" before tryingAttention or concentration difficulties

Reading comprehension is low

Whispers to self during readingDifficulty seeing with the "mind's eye" what is readTrouble remembering what has been seen beforeDifficulty with math concepts

Difficulty or slow to learn left from rightLetter, number, or word reversals

Poor walking/posture; leans back on heels, forward on toes or to side

Auditory-Visual Integration Never Seldom Occasionally Frequently

Visual-Motor Integration Never Seldom Occasionally Frequently

Visual-Vestibular Never Seldom Occasionally Frequently

Poor coordination & balance or athletic performanceClumsiness, bumps into things, or knocks things overGood coordination but poor at catching/hitting a ball

Poor spelling even after studying

Perception of floor being tiltedLimited peripheral vision

Spatial disorientationConsistently stays to one side of the hallway or room

Difficulty linking what is heard or seen

Sloppy writing or drawing skillsErases excessively

Difficulty copying from the boardTrouble finishing written assignments in time allowed

Trouble sounding out new wordsPoor letter to sound matchingNeeds directions repeated

Must learn new words over and overReading speed is very, very slow

Mouth/lips move during silent reading

Poor sense of balance or equilibrium

Dizziness while walking up/down stairs

Headaches or eye pain when exposed to a bright light

Trouble gripping pen/pencil

Motion sicknessDizziness or nausea after visual movement

Dizziness while watching minimal motion

Feels overwhelmed by vision

Nausea while reading in a car

Seems to know the material, but does poorly on testsDifficulty writing numbers so they line up for math problems

Can give good answers aloud, but not in writing