Patient Registration Form Patient Details

Patient Registration Form Contact Information

Patient Registration Form Health History

Do you currently have any problems in the following areas, please check the box and provide information.

  •  Diabetes Type 1
  •  Diabetes Type 2
  •  High Blood Pressure
  •  Elevated Cholesterol
  •  Plaquenil Use
  •  Hydroxychloroquine Use
  •  Methotrexate Use
  •  Cancer
  •  Ears/Eyes/Nose Throat (Stuffy nose, ear ache, etc)
  •  Fever
  •  Weight Loss
  •  Respiratory (congestion, wheezing. etc.)
  •  Gastrointestinal (stomach upset ,diarrhea, constipation, etc.)
  •  Genital, Kidney, Bladder (painful urination, frequent urination, impotence, etc.)
  •  Muscles, Bones, Joints (Joint pain, stiffness, swelling, cramps, etc.)
  •  Skin(pimples, warts, growths, rash, etc.)
  •  Neurological (numbness, headache, etc.)
  •  Psychiatric (anxiety, depression, insomania)
  •  Endocrine (diabetes, hypothyroid, etc.)
  •  Blood/Lymph (cholesterolemia, anemia, etc.)
  •  Allergic/Immunologic (sneezing, swelling, redness, itching, hives, etc.)
  •  Yes
  •  No
  •  Yes
  •  No

Patient Registration Form Eye History

  •  Blurred Distance Vision
  •  Blurred Near Vision
  •  Blurred Computer Vision
  •  Headaches
  •  Flashes / Floaters
  •  Burning
  •  Itching
  •  Dryness
  •  Glasses
  •  Contacts
  •  Yes
  •  No
  •  Yes
  •  No
  •  Soft
  •  RGP
  •  Scleral

Internal Retinal Evaluation (Dilation)

The most important part of maintaining great vision is assuring that your eyes are healthy. We acheive this by performing what is known as a dilation. Thankfully, new technology provides many options for examing the health of your eyes. We offer traditional Drop Dilation which has side effects of Blurred Near Vision and light sensitivity. We also offer the Dropless Optomap Retinal Imaging. In addition to the drop-less Optomap Digital Retinal Technology, Dr. Davis has added the iWellness Laser Scanning Instrument. This new instrument allows for the detection of glaucoma, macular degeneration, and diabetic retinopathy. We offer both scans at a reduced price when performed as a bundle:

  •  Optomap $20
  •  Dilation by Drop $0
  •  Bundle (Optomap and iWellness) $30
  •  iWelness Only $15
  •  Decline
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Patient Registration Form Family History

  •  Diabetes
  •  Lupus
  •  Thyroid
  •  Cancer
  •  Hypertension
  •  Stroke
  •  Rheumatoid Arthritis
  •  Macular Degeneration
  •  Retinal Detachments
  •  Keratoconus
  •  Glaucoma

Patient Registration Form COVID-19 Questionnaire

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Patient Registration Form Office Policies

We appreciate your trust in our ability to continue to provide your care. Please read over and acknowledge our policies below. 

Privacy Policy: Modern Eyez Will keep a record of the health care services we provide to you. You may request a copy of your medical record in writing. We will not disclose your record to others unless you direct us to do so or unless legal authorities authorize or compel us to do so. You may request a copy of your medical record or get more information by contacting our practice. Our Notice of Privacy Practices is available at the reception desk and is posted in the clinic. The Notice describes in greater detail how your health information may be used or disclosed, and how you can access your information. You are entitled to a copy of this Notice and it is available at your request.

I acknowledge the Notice of Privacy Practices has been offered to me and is readily available in accordance with the Health Insurance Portability and Accountability Act.

Authorization to Release Medical Information: I agree and authorize the release of medical information regarding myself/my dependents and my current condition to my referring, consulting, or treating physicians.

Financial Responsibility: Payment for all professional services rendered is due at the time of service. If you have health insurance, it is your responsibility to ensure we have correct and current information for your insurance plan. It is also your responsibility to pay the copay at the time of service per our contract with your insurance plan. If you are not using health insurance,  payment for services rendered is required at the time of service.

Vision Coverage: Fees for Services and Materials are due at the time of your visit. You are responsible for any elective options not covered by your Vision Plan, including upgrades on frames, lenses, the Optomap, contact lens fees, and copays. In NM, patients are charged sales tax on all materials.

Medical InsuranceDuring check-in, you may be asked to provide your Medical Insurance information. In the event that we encounter a significant medical problem with your eyes during your visit, Modern Eyez will attempt to coordinate benefits between your Medical Insurance and Vision Coverage Plan. It is important to note that Vision Plans do not cover the diagnosis or treatment of medical conditions of the eyes. Coordination of benefits will help reduce the out-of-pocket cost you may incur. Determination of eligibility is not a guarantee of payment by your Insurance Plan(s).

Eye Health Evaluation: The most important part of maintaining great vision is assuring that your eyes are healthy. Thankfully, new technology provides many options for examining the health of your eyes. In addition to the drop-less Optomap Digital Retinal Technology, Dr. Davis has added the iWellness Laser Scanning Instrument. This new instrument allows for the detection of glaucoma, macular degeneration, and diabetic retinopathy. We offer both scans at a reduced price when performed as a bundle:

Contact Lens Evaluation: There is an additional fee for the evaluation and management of contact lenses. Dr. Davis must determine the correct curvature, make sure the cornea is healthy enough to wear contact lenses, manage contact lens-related problems, verify that visual acuity is satisfactory, and she brings her education, training and 25+ years of experience to bear on this process. Your insurance company does expect us to charge a fee for the determination of a contact lens prescription.

Using your own frame: We are happy to use your own frame for your order, and will inspect it to make sure it is likely to withstand the process of replacing the lenses. We may send your order to outside labs for completion.  Modern Eyez cannot be responsible if the frame is broken, damaged, our lost when it is out of our hands, and we will not be able to replace it.

Restyle:  Don’t like the frame? Not adapting to the lens? You have 30 days from the day we receive the completed order to RESTYLE. You can choose a frame of equal value at no charge or greater value and pay the difference. You can change the lens style, material, or add-ons as well and be charged for upgrades from the original order.

Returns:  We promise we will do whatever we can to make sure you are 100% satisfied with your order. However, there are those few occasions that you may want to return your order. Even though it breaks our heart to hear you were not satisfied as long as you are within 30 days from us receiving the order you can return your order.

Refunds: Although it breaks our heart to know that you were not satisfied with your order and are requesting a refund. We are here to make sure this is a simple and painless process. As long as you fall within the 30-Day return policy you can receive a refund for your purchase minus the cost Modern Eyez was billed for the order. If you used your insurance we will make sure to reverse your benefits. Sometimes when reversing your benefit, it can take up to 2 weeks before you are able to use it elsewhere. Paid with a credit card? That also can take up to 72 hours before you see the refund. A full copy of our policies regarding refunds, returns, and exchanges is available for pick-up at the front desk.

 

 

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Patient Registration Form COVID - 19 Policies

At Modern Eyez we take the health of our Patients and Staff seriously. Here are a few updates we have made to protect anyone who enters our facility.

Scheduling:

  • Our door will be locked at all times. Please Call 505-896-2010 upon arrival for your appointment.
  • We have lengthened our Scheduled Exam Time to make sure we give ourselves enough time to properly disinfect all touched surfaces.
  • Pick Up for Glasses are to be scheduled to limit the amount of people in the office at one time.
  • We are only allowing the person who is scheduled to enter the facility. (Exception would be any person under the age of 18 or individuals with special needs. We will allow 1 parent or guardian)
  • We will allow only 10 minutes for late arrivals. Anyone later than 10 minutes will be rescheduled. 

Contact Lens Dispensing:

  • All Dispensing for Contact Lenses will be done curbside. Just call us when you arrive.   

Internal Health Evaluation:

  • To facilitate patient flow into and out of the office, we are offering our Optomap Retinal Exam at 50% off.
  • This dropless, touchless technology allows for quick, sanitary evaluation of the inside of the eye, known as the Retina.
  • Dilation with eyedrops will still be performed on an as-needed basis.
  • We respect your right to refuse the Optomap, but urge you to take advantage of this technology and reduce your risk of both undiagnosed retinal problems and exposure to more touch-points and time spent in the office.

Requirements:

  • Screening questions are a requirement.
  • Before entering the building, all Patients will have their temperatures taken and logged.
  • Face Coverings are required for the duration of your visit.
  • Once you are cleared to enter, we will have you wash your hands (for 20 seconds) at our handwashing station.
  • Social distancing is encouraged when possible.

Purchasing:

  • To limit contamination when browsing our frame selection be sure to advise our Optician which frames you would like to try on. They will pull them for you to try on. This will allow us to keep track and provide proper sanitation afterwards.
  • Please provide us with an Email address so we are able to send you a copy of your receipts and/or prescriptions.

                   

 

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