Do you presently wear glasses? YesNo
Do you presently wear contacts? YesNo
Have you ever worn contacts? YesNo
List any current medications and the reasons for taking them.
Distance Vision Blurry YesNo
Middle Distance Blur YesNo
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
Eye Strain / Fatigue YesNo
Seeing Spots or Lines YesNo
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
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
I was referred by
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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)?
I authorize this office to release any information to third-party payers for billing purposes. I authorize and request my insurance company to pay my insurance benefits to Accent Eye Care. I acknowledge that I am financially responsible for any services/materials and claims not covered and /or denied by my insurance for myself and my dependents. Returned checks incur a
$30 fee. Appointments not cancelled within 24 hours are subject to a $30 fee. Accent Eye Care is not responsible for previously used frames and/or lenses which are being reused or adjusted at my request. Eyeglass lenses and frames are non-returnable and non-refundable medical devices. Eyeglass frames are warranted only for manufacturer’s defects one time within one year of purchase; shipping, handling and restocking fees will apply. Prescription accuracy is warranted and must be reported within 60 days from date of exam with a one time redo of lenses purchased here. Unmarked and unopened contact lens boxes may be exchanged within 60 days from date of exam; a restocking fee will apply. Contact lens fittings are non-refundable. I understand that all fees may be subject to change without notice. Any balance owed by you or the guarantor is subject to a 1.5% late fee (18.0% annum) to be assessed monthly until we receive payment in full. If the account is referred to a collection agency there will be a collection fee of up to 30% over the principle assessed and any applicable fees.
Purpose of Today's Visit. (Please check all that apply)*:GlassesContact LensesTherapeutic/vision TherapyAnnual ExamOther