Accent-Eye-2021-New-Slider-image-Front-page-1024×428-updated

Welcome to our office!

Which is more damaging
blue light or UV?
Ask us at your next visit.

Latest styles for all your needs

Vision care for the entire family
starting at infancy!

Looking for an edge?
Sports vision training for all levels.

602-547-3255
patientcare@accenteyes.com

16020 North 35th Avenue
Suite 2
Phoenix, AZ 85053

OUR OFFICE HOURS

MON - THUR - 9:00AM - 6:00PM
TUE - 9:00AM - 6:30PM
FRI - 8:00AM - 2:30PM

602-547-3255 patientcare@accenteyes.com

Home
ABOUT
SERVICES
VISION THERAPY
OUR TECHNOLOGY
PATIENT FORMS
News
CONTACT US

Home
ABOUT
SERVICES
VISION THERAPY
OUR TECHNOLOGY
PATIENT FORMS
News
CONTACT US

New Patient Intake Form Old

/New Patient Intake Form Old

Welcome to our New Patient Intake Form, please be aware that this is a multi-step form. Check everything and make sure you have filled out the required fields before going to the next step.

Mr.Mrs.MissMs.Dr.

Are you interested in: (Please check all that apply)
GlassesContact lensesTherapeutic/Vision Therapy

Do you presently wear glasses? YesNo

Do you presently wear contacts? YesNo

Have you ever worn contacts? YesNo

MEDICAL HISTORY (needs to be completed for the examination)

List any current medications and the reasons for taking them.

CONTACT LENS INFORMATION (Please skip this box if you do NOT wear contacts)

(if not known, please check which types):
SoftHard/Gas PermeableDisposableMonovisionBifocalColored

NOTE: All lenses are not suitable for all patients. We will discuss what’s available for your particular prescription, fitting parameters and lifestyle after the completion of your examination.

Do you suffer from any of the following (Please select one)

with glassescontacts if wornwithout correction

Distance Vision Blurry	YesNo
Middle Distance Blur	YesNo
(Dashboard/ Computer)
Near Vision Blur	YesNo
Burning Sensation	YesNo
Double Vision	YesNo
Itchy Eyes	YesNo
Pain In or Around Eyes	YesNo

Seeing Flashes	YesNo
Dry/Scratchy/Watery Eyes	YesNo
Problems with Focusing	YesNo
Headaches	YesNo
Glare	YesNo
Eye Strain / Fatigue	YesNo
Seeing Spots or Lines	YesNo

Dilated at that exam? YesNo

Do you or any BLOOD relatives currently suffer from or have a history of:

High Blood Pressure	YesNo
Color Blindness	YesNo
Cataracts	YesNo
Diabetes	YesNo
Glaucoma	YesNo
Heart Disease	YesNo

Allergies/Sinus	YesNo
Amblyopia (lazy eye)	YesNo
Macular Degeneration	YesNo
Retinal Detachment	YesNo
Eye Injury	YesNo
Keratoconus	YesNo
Endocrine	YesNo

Arthritis	YesNo
Gastrointestinal	YesNo
Respiratory	YesNo
Kidney/Bladder	YesNo
Blood/Bleeding	YesNo
Skin Disease (e.g. eczema)	YesNo
Mental	YesNo

Significant weight loss/gain/fatigue

Do you smoke?	YesNo
If yes, how often?	DailyOccasionally
If no, have you ever smoked?	YesNo

Do you use recreational drugs?	YesNo
If yes, how often?	DailyOccasionally
Do you drink alcohol?	YesNo
If yes, how often?	DailyOccasionally

PUPIL DILATION

Dilated exams provide the doctor with a more comprehensive view of the retina (back layer of the eye) and are essential in the early detection and prevention of many eye diseases. Dr. Gong strongly recommends dilation. Eye drops are required and your near vision will remain blurred and light sensitive for several hours. When dilated, we advise you to exert caution when driving.

Please indicate if you wish to have the dilation test done today:*

YesNoRescheduleDiscuss with doctor

RETINAL PHOTOS

A retinal photo gives Dr. Gong a detailed picture of the back of your eyes. This can help detect conditions such as glaucoma, diabetes, hypertension, and retinal detachment, among many others. These photos will be saved in your file to compare to over the years.

Please indicate if you wish to have Retinal Photos done today:*

YesNoDiscuss with doctor

REFERRAL, PAYMENT AND AUTHORIZATION

I was referred by

Our WebsiteInternetInsurance CompanyMonovisionOther

Payment is expected in full when services are rendered. Eyeglasses and contact lenses must be paid for in full. Who is responsible for your bill (those charges not covered by insurance)?

1 Psychiatric	DepressionPanic DisorderSchizophreniaOtherNone
2 Endocrine	Non-Insulin Dependent DiabetesInsulin Dependent DiabetesThyroid DysfunctionHormonal DysfunctionOtherNone
3 Musculoskeletal	FibromyalgiaMuscular DystrophyOsteoarthritisAnkylosing SpondylitisOtherNone
4 Cardiovascular	Heart DiseaseHypertension (High Blood Pressure)StrokeVascular DiseaseOtherNone
5 Allergic/Immunologic	Drug AllergyEnvironmental AllergyRheumatold ArthritisLupusOtherNone
6 Genitourinary	STD, Viral Herpetic, ChlamydiaOtherNone
7 Gastrointestinal	Crohn'sColitisUlcerDigestiveOtherNone
8 Neurological	Multiple SclerosisEpilepsyAlzheimersParkinsonsCerebrovascularOtherNone

9 Eyes	GlaucomaCataractsMacular DegenerationSurgeryInflammartory DisordersBlurred VisionDouble VisionOtherNone
10 Hematologic/Lymphatic	AnemiaLarge Volume Blood LossLeukemiaOtherNone
11 Ear,Nose,Mouth,and Throat	Upper Respiratory Track InfectoinEar AcheRunny NoseSore ThrosatRinging/TinnitisOtherNone
12 Respiratory	AsthmaBronchitisEmphysemaOtherNone
13 Integumentary	EczemaRosaceaPsoriasisOtherNone
14 Constitutional	Developmental DisabilityWeight LossFeverFatigueTraumaOtherNone

Drug Allergies

Purpose of Today's Visit. (Please check all that apply):GlassesContact LensesTherapeutic/vision TherapyAnnual ExamOther

INFO

602.547.3255

MAKE AN APPOINTMENT ONLINE

Contact Us today to schedule your appointment!

Our Office Hours
M-Th: 9:00 AM – 6:00 PM
Tues: 9:00 AM – 6:30 PM
Fri: 8:00 AM – 2:30 PM

Connect With Us

Testimonials

Dear Dr. Gong,

"I wanted to thank you for all of your help with my vision correction over the last few months.

Coming to your office was a wonderful experience after my retinal surgery! Given the complications after the surgery, I am grateful for you giving me extra time to help me regain my vision.

During my first visit, your staff welcomed me into the office and used multiple diagnostic modalities to identify the reasons for my vision difficulties. I was amazed at the time that you spent personally with me, asking questions, performing tests and reassuring me that we would find the answer. My experience with you and your staff was so different from my previous experiences that I have referred several of my fellow physicians to you for difficult vision correction. I also would like to commend you on creating an environment where patients are seen quickly yet feel that you and your staff really care about their health.

Thank you so much for your care.

Respectfully,

Dr. William Resnick

Prescott Emergency Medicine

Referred by USC Ophthalmology

See More Testimonials...

CHECK TO SEE IF WE ACCEPT YOUR INSURANCE?

New York Yankees demonstrating their workout for improving hand-eye coordination on our Senaptec sensory station.

602-547-3255 patientcare@accenteyes.com

Welcome to our New Patient Intake Form, please be aware that this is a multi-step form. Check everything and make sure you have filled out the required fields before going to the next step.

**MEDICAL HISTORY** (needs to be completed for the examination)

CONTACT LENS INFORMATION (Please skip this box if you do NOT wear contacts)

Do you or any BLOOD relatives currently suffer from or have a history of:

Significant weight loss/gain/fatigue

PUPIL DILATION

RETINAL PHOTOS

REFERRAL, PAYMENT AND AUTHORIZATION

Psychiatric

Endocrine

Musculoskeletal

Cardiovascular

Allergic/Immunologic

Genitourinary

Gastrointestinal

Neurological

Eyes

Hematologic/Lymphatic

Ear,Nose,Mouth,and Throat

Respiratory

Integumentary

Constitutional

602-547-3255
patientcare@accenteyes.com

MEDICAL HISTORY (needs to be completed for the examination)