LAKE POINT VISION	 8185 Highway 242, Conroe TX 77385
	Dr. Oanh Le  Dr. Jizhao Yang	 Office (936)-703-2310  Fax (936) 703-2311
	WELCOME TO OUR OFFICE
Mr./Mrs./Ms./Dr.  ___________________	______	________________________   Date: __________
	First Name	Middle	Last Name
Address: _________________________________________________________	City:__________________ 
State:_____________   Zip:_______________  Occupation:___________________________
		                          Date of Birth:_________________ Age:_________ Sex:  M     F     E-mail:____________________
	
Home Phone: ____________________Work Phone: ______________ Cell Phone: __________________
	
Method of      Cash    Credit Card         Insurance:
Payment:   (we do NOT accept check)

Insurance Agreement:  I hereby authorize this vision care provider to apply for benefits in my behalf for covered service by them.
I also assign my benefit and request all payment from my insurance directly to my vision care provider.
I authorize this vision care provider to release to the insurance company any information related to this or any related item.
I agree to the responsibility of full payment pending any remaining balance that is not covered by the insurance company.
If, within 90 days of the initial office visit, the doctor or staff believes that an additional office visit will be necessary to recheck the prescription, then this additional visit will be scheduled at no additional charge. Re-check visits after 90 days WILL be charged an additional refraction fee.

GENERAL HEALTH HISTORY:	
Date of Last Physical: ________ If applicable, are you pregnant?  Yes  or  No  If yes, how long___________    Medications:_______________________________________________________________________________                          Drug Allergies:_____________________________________________________________________________	
HIV Positive  (if yes, please notify doctor only)		        				

(Please check Y = yes, N = no, or F = family)	Y	N	F	
Headache / Migraines					
Thyroid Problems					
Cancer				
Asthma				
Heart Problems				
Diabetes				
Cholesterol				
Hypertension				
Other (please specify): 
	
GENERAL EYE HISTORY:	
Reason for today's visit:	 Glasses	         Contact Lenses	       Other _______________________ 	
Last Eye Exam Date: ______________	
How did you hear about us?		Postcard			Referral	
Have you ever worn contact lenses?	Yes			No
   If yes, please fill out the information below:
   How's comfort? _____________________________	
	Previous Contact Lenses brand	_________________ Replacement:  1 Day    2 Weeks   1 Month	1 Year
	Power:	 Right Eye 	______________ 	Left Eye _______________ Sleep-in contact lenses?	   Yes	   No
	How old are contact lenses?	________________________Average wearing time: ______________________
	How's vision?	__________________________Solution used:	______________________________________
   
(Please check Y = yes, N = no, or F = family)	Y	N	F	
Blurred Distance Vision				
Blurred Near Vision					
Double Vision				
Burning or Itching				
Retinal Detachment				
Macular Degeneration				
Glaucoma				
Cataract				
Floaters				
Light Flashes				
Eye Injury / Eye Surgery				
Other (please specify): 	
	 
PUPIL DILATION:  I agree to dilation (No Additional Cost)         Yes    No     Discuss with Doctor
Pupil dilation allows the doctor to examine the retina (back of the eye).  Dilation can detect many conditions within the eye that may not be detected during a routine eye exam. Dilation is strongly recommended for individuals with a history of diabetes, glaucoma, cataract, high nearsightedness, high blood pressure, sudden change in vision, or any conditions that affect the integrity of the retina.  Side effects are sensitivity to light that lasts 4-6 hours and trouble focusing up close for 2-3 hours.

VISUAL FIELD TEST:  I agree to a visual field screening ($20.00)   Yes    No     Discuss with Doctor
This test checks for loss of sight in your peripheral and central vision possibly due to glaucoma, cataracts, macular degeneration, retinal detachments, and/or neurological diseases. The doctor highly recommends a visual field exam especially if you have a history of headaches, migraines, flashes floaters, a sudden change of vision, or a family history of glaucoma.

OPTOMAP: I agree to Optomap photos ($35.00)  		       Yes    No     Discuss with Doctor
The Daytona Plus Optomap is the LATEST ultra-wide field retinal imaging machine. It's a unique technology that captures more than 80% of your retina in one panoramic image while traditional imaging method typically only show 15% of your retina at one time.
The doctor strongly recommends Optomap. While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough screening of the retina is critical to verify that your eye is healthy. It can lead to early detection of common diseases, such as Glaucoma, Diabetes, High Blood Pressure, Macular Degeneration, Bleeding in the retina and even Cancer. This is a quick test, painless, and does NOT require dilation drops.
Acknowledgement of the Federal HIPPA Privacy Practices                                           
I acknowledge that I have received and/or read a copy of the Notice of Privacy Practices.   

Signature: _____________________________________             Date: _________________________
(Parent or guardian must sign if patient is a minor)