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Meagan Nichols
5 years ago
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1 WELCOME TO OUR PRACTICE information completely: 1. Patient Information: Social Security No: Address: Name: (Last) (First) (M.I.) Address: City: State: Zip Code: Home Phone: Cell Phone: Date of Birth: Sex: M F Marital Status: S M D W Preferred Language: English Spanish Other Race: American Indian Alaska Native Asian African American Caucasian Ethnicity: Hispanic or Latino Not Hispanic or Latino Decline to answer Employed: No Full Time Part Time Retired Business Phone: Name of Employment or School: 2. Guarantor Information: Social Security No: Address: Name: (Last) (First) (M.I.) Address: City: State: Zip Code: Home Phone: Cell Phone: Date of Birth: Sex: M F Marital Status: S M D W Employed: No Full Time Part Time Retired Business Phone: Name of Employment or School: 3. Insurance Information: Primary Insurance: Policy #: Insured s Name: DOB: Insured s SS# Insured s Employment: Work Phone: Secondary Insurance: Policy #: Insured s Name: DOB: Insured s SS# Insured s Employment: Work Phone: 4. Appointment Information: Family Doctor: Referring Doctor s Name: Who is your eye doctor? How did you hear about us? List any family members who are patients: Emergency Contact: Name: Relationship: Phone No: Pharmacy: Pharmacy Name: Pharmacy Location: Pharmacy Phone:

2 Patient Name: Eye History: DOB: Have you experienced or been diagnosed with any of the following: Cataract Retinal Detachment Diabetes Glaucoma Dry Eyes Migraines Amblyopia Macular Degeneration Other Please describe the reason for your visit: Have you ever experienced a serious eye injury or had eye surgery? Explain: Date of your last exam: Please list any eye drops or eye medications you are currently using: Medical History: Do you have any medication allergies? If so, please list: Have you ever been diagnosed with any of the following? Asthma Cancer Heart Disease Stroke Arthritis Bleeding Disorder Thyroid High Blood Pressure Diabetes Please list your current medications and dosages: Please list prior major surgeries: Family History: Has anyone in your immediate family been diagnosed with any of the following? Glaucoma Heart Disease Macular Degeneration Cataract Diabetes Crossed or Lazy Eye Blindness Other Social History: Do you smoke? Yes / No If so, how many packs per day? Has there been any change in your weight in the past 6 months? Yes / No Gain / Loss Do you drink alcoholic beverages? Yes / No If so, how much? Socially / With Meals / 2-3 Per Week / More Are you pregnant or planning? Yes / No Your Occupation: How long: Reviewed with patient by: On:

3 Patient Name: Kindly complete this form to assist us in more fully understanding the present condition of your eyes. VISUAL FUNCTIONING Do you have difficulty, even with glasses, with the following activities? Yes No 1. Reading small print, like labels on medicine bottles, telephone books, or food labels? 2. Reading a newspaper or book? 3. Reading a large-print book/newspaper, or large numbers on a telephone? 4. Recognizing people when they are close to you? 5. e d n r c n, ree n, or ore n 6. Do n ne nd or l e e n, n n, croc e n, or c r en ry 7. r n c ec or ll n o orm 8. Taking part in sports like bowling, handball, tennis, or golf? 9. Cooking? 10. c n ele on SYMPTOMS Have you been bothered by: 1. oor n on 2. Seeing rings or halos around lights? 3. Glare caused by headlights or bright sunlight? 4. Hazy and/or blurry vision? 5. See n ell n oor or d m l DRIVING 1. Do you currently drive a car? Yes No* *If NO, when did you stop driving? Less than 6 months ago 6-12 months ago More than 1 year ago 2. Ho m c d c l y do yo e dr n d r n e d y ec e o yo r on o d c l y Mild: noticeable but I don t really think about it Moderate: noticeable, distracting, and I would like it made better Severe: unable to drive at day anymore, must be made better 3. Ho m c d c l y do yo e dr n n ec e o yo r on o d c l y Mild: noticeable but I don t really think about it Moderate: noticeable, distracting, and I would like it made better Severe: unable to drive at night anymore, must be made better Cataract surgery can almost always be safely postponed until you feel you need better vision. Are you ready to proceed with Cataract surgery? Yes No Patient Signature Date Kerry D. Solomon, MD Jeffrey Hood, OD DrKerrySolomon.com (843)

4 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT WHAT IS THIS NOTICE ABOUT AND WHY IS IT IMPORTANT? This notice is required by the U. S. Department of Health and Human Services in order for me to be informed of how my health information will be used, disclosed, and protected, and about my rights regarding my health information. I understand that under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used: For Treatment: We are permitted to use your health information or disclose it to others outside Carolina Eyecare Physicians, LLC in order to provide, plan and direct proper medical care for you. For Payment: We are permitted to disclose health information about your treatment and services in order to submit bills for the care and services you received, and collect payment from you, your insurance company or a third party payer. For Health Care Operations: We are permitted to use your heal th information to assess the care and the outcome in your case and others like it, in order to assure the highest quality of care for our patients. When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave messages on your answering machine/voice mail. I understand your Notice to Privacy Practices containing a more complete description of the uses and disclosures of my PHI is available to me. I understand that this organization has the right to change its notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. (Please circle one) Patient name: Signature (of Patient or Legal Guardian): Date: DOB: Practice Use Only I attempted to obtain the signature of the patient or legal guardian in acceptance of the Notice Of Privacy Practices Acknowledgment but was unable to do so as documented below: Date: Initials: Reason:

5 FINANCIAL RESPONSIBILITY AND WAIVER/RELEASE I understand that it is the patient s responsibility to supply CAROLINA EYECARE PHYSICIANS, LLC with any current insurance information and/or any referral authorization forms that may be necessary for my insurance. I am aware that if I have a routine diagnosis my Insurance may not cover this appointment. If this account results in collection agency involvement, the undersigned guarantor agrees to pay all legally allowed interest and associated fees. I authorize CAROLINE EYECARE PHYSICIANS, LLC to receive all payments for medical services rendered to my dependents or UNPAID BALANCES. prescriptions) and that I will be fully responsible for these charges. I understand that insurance companies require are rendered. additional charge. several hours. I recognize that operation of a motor vehicle after dilation may be hazardous and I have made appropriate arrangements. 1) Date: Signature I authorize CAROLINA EYECARE PHYSICIANS, LLC to obtain information from other physicians that they may feel 2) Date: Signature Reviewed by:

$CAROLINA EYECARE PHYSICIANS WHAT IS A REFRACTION? Refraction is the optical determination of your best possible vision in each eye.$ No visual complaint can be addressed without this service and you may not receive a prescription for glasses or contacts if this service is not performed. The fee for this service is $50.00.

No visual complaint can be addressed without this service and you may not receive a prescription for glasses or contacts if this service is not performed. The fee for this service is $50.00.

6 CAROLINA EYECARE PHYSICIANS WHAT IS A REFRACTION? Refraction is the optical determination of your best possible vision in each eye. It is necessary to perform a refraction to determine if any medical, optical, or surgical treatment may be indicated. Your doctor recommends a refraction at the time of your annual exams. No visual complaint can be addressed without this service and you may not receive a prescription for glasses or contacts if this service is not performed. The fee for this service is $ Most insurance companies do not cover it. I hearby acknowledge that I have read the above and indicate below with my signature that I agree to have this service performed. Signature of Patient Date Kerry D. Solomon, MD Jeffrey Hood, OD DrKerrySolomon.com (843)

7 CAROLINA EYECARE PHYSICIANS Dear Valued Patient, We want to thank you for putting your trust in Dr. Kerry Solomon and his team of eye care experts. We realize that fading vision due to a cataract can be a scary time, but cataract surgery has undergone tremendous advances since the days of your parents and grandparents. Today it is safer and more precise with advanced technologies to enhance your lifestyle by restoring your youthful vision! Once you understand what a cataract is, how it is removed and how your vision may be improved with the latest options Dr. Kerry Solomon offers, your concern could actually turn into excitement! We look forward to seeing you soon! Advanced Vision Testing We would like to inform you about our Advanced Vision Testing in preparation for your visit. Dr. Kerry Solomon strongly recommends this testing for all of his patients during a cataract evaluation for the following reasons: It is required in order to be eligible for and to determine your candidacy for any advanced options, including Laser Cataract surgery and Premium Lifestyle Lens Implants. This testing can detect early signs of eye conditions, such as Macular Degeneration, that standard tests cannot. This additional testing will give you a complete look at the health of your vision and help you make better, more informed decisions regarding your care. The Advanced Vision Testing will include Verion Testing, Corneal Topography, Macula OCT and a manual Keratometry (when necessary). The cost for Advanced Vision Testing is $150 and is not covered by insurance. Verion Testing: Captures detailed measurements and data to use during surgery to create a customized procedure and improve outcomes when correcting astigmatism. Corneal Topography: A three-dimensional map of the outer surface of the eye providing a more accurate analysis of your refractive errors. Macula OCT: Optical Coherence Tomography or OCT assists in detecting many eye diseases including macular degeneration, diabetic retinopathy and glaucoma. Yes, I elect for Advanced Vision Testing today. I understand there is a fee of $150 due at the time of my testing and is not covered by insurance. I understand I have the option to have Advanced Vision Testing. I would first like to consult with Dr. Solomon. I understand if I choose Advanced Vision Testing later it will require an additional visit. No, I decline Advanced Vision Testing. I understand I will not be eligible for any refractive options that can help me gain independence from my glasses and enhance lifestyle. Signed Date (843) (843) DrKerrySolomon.com Mt. Pleasant West Ashley North Charleston Summerville

8 Cataract Surgery Eye Drop Options/Instructions We offer three options of surgery drops for use before and after your Cataract Surgery. We understand these drops can become costly therefore our goal is to provide you an option that is most affordable for you. Please review all three options and indicate your choice of drops by checking the box next to the option you prefer. If you have any questions, we will discuss them with you at the time of your appointment. Option 1: BRANDED EYE DROPS VIGAMOX (Antibiotic) Start 3 days before surgery. Use one (1) drop in operative eye four (4) times per day. Continue for two (2) weeks after surgery then stop. ILEVRO (Non-Steroidal Anti-Inflammatory) Start 3 days before surgery. Use one (1) drop in operative eye one (1) times per day. Continue for four (4) weeks after surgery then stop. DUREZOL (Steroid Anti-Inflammatory) Start using one (1) hour prior to surgery arrival. Use one (1) drop in operative eye every fifteen minutes. After surgery continue four (4) times per day for two (2) weeks Beginning the third (3) week after surgery use one (1) drop two (2) times per day for two (2) weeks then stop. SHAKE ALL BOTTLES BEFORE USING USE 3 MINUTES APART * The cost will vary based on your insurance coverage. Many of our patients have reported these drops cost in excess of $ These drops are available at your local pharmacy. Option 2: GENERIC EYE DROP SUBSTITUTIONS OFLOXACIN (Antibiotic) Start 3 days before surgery. Use one (1) drop in operative eye four (4) times per day. Continue for two (2) weeks after surgery then stop. KETOROLAC 0.5% (Nonsteroidal Anti-Inflammatory) Start 3 days before surgery. Use one (1) drop in operative eye four (4) times per day. Continue for two (2) weeks after surgery. Beginning the third (3) week after surgery use one (1) drop two (2) times per day for two (2) weeks then stop. PREDNISOLONE ACETATE (Steroid Anti-Inflammatory) Start using after surgery Use one (1) drop to operative eye four (4) times per day for two (2) weeks. Beginning the third (3) week after surgery use one (1) drop two (2) times per day for two (2) weeks then stop. SHAKE ALL BOTTLES BEFORE USING USE 3 MINUTES APART * The cost will vary based on your insurance coverage. Many of our patients have reported these drops cost in excess of $ These drops are available at your local pharmacy. Option 3: COMPOUNDED EYE DROP PRED-MOXI-KETOR (Antibiotic, Non-Steroidal Anti-Inflammatory, Steroid Anti-Inflammatory) Start one day before surgery. Use One (1) drop three (3) times a day in the operative eye. Use until gone. *The cost is $60.00 per bottle plus $10.00 shipping and handling. This drop is not covered by most insurance plans. If you choose this option Imprimis pharmacy will contact you within 24 hours to take payment and confirm mailing address. These drops are delivered to your home and are not available at your local pharmacy. Imprimis Pharmacy: (858) *You are not able to take advantage of this option if you have an allergy to Levaquin or Vigamox antibiotics. ** If you have agreed to participate in a research study, this option may not be available.

Name: (Last) (First) (M.I.) Address: City: State: Zip Code:

WELCOME TO OUR PRACTICE information completely: 1. Patient Information: Social Security No: E-Mail Address: Name: (Last) (First) (M.I.) Address: City: State: Zip Code: Home Phone: Cell Phone: Date of Birth: