Gender

Address

Phone Number

When was your last exam?

Do you wear glasses for?

Do you have blurred DISTANCE vision?

Do you have blurred NEAR vision?

Are you interested in LASIK eye surgery for vision correction? The initial consultation is free

Do you wear contact lenses?

If no, are you interested in contact lenses?

Do you have any issues with your current contact lenses?

Have you ever had eye surgery?

Do your eyes feel tired or strained?

Do you experience any headaches?

Do your eyes burn/feel dry?

Do you see bright flashes of light?

Do you see floating spots in your vision?

Do you experience double (not blurred) vision?

Are you at the computer the majority of your day?

Cosmetic Concerns

Do you have any cosmetic concerns?

CLICK BOXES for the following:

High blood pressure

Diabetes

High Cholesterol

Heart Disease

Thyroid Disease

Cancer (or history of)

Glaucoma

Macular Degeneration

Retinal problems

Other medical problems:

Do you smoke?

Do you consume alcohol?

Females, are you pregnant/breastfeeding?

Are you currently taking any prescribed OR over-the-counter medications (including eye drops)?

Are you allergic to any medications?

REQUIRED: I have read and understood the Notice of Privacy Practices.

Our optometrists perform both routine eye exams for glasses and contacts, as well as medical eye exams. Should your exam include additional testing and treatment for a medical eye condition (ex: dry eye, diabetes, ocular allergies, or glaucoma), your medical insurance may be billed. Please let our staff or your optometrist know if you have any questions regarding this policy.

Contact Lens Examination

Financial Responsibility

We believe that you should not be surprised by your eye care costs. Enclave Vision will always do our best to verify your insurance eligibility prior to your appointment. There may be times that our doctors feel that a certain procedure is appropriate and necessary but is not covered by your insurance plan. We will provide you an estimated cost of these procedures when requested. When a patient agrees to any necessary procedure that is not covered by insurance, the patient is responsible for payment at the time of service.

Eye Health Screenings

Clarus digital image of the retina

Our doctors would like all patients over the age of 4 to have the Clarus retinal image performed every year. This technology provides an ultra wide-field view of the retina and important structures of the eye and eliminates the need for dilation drops in many (not all) cases. Comparing these images on an annual basis allows for early detection of eye disease. The fee for this image is $30 and is not usually covered by insurance.

OCT (Ocular Coherence Tomography)

An OCT screening can detect the earliest signs of certain eye diseases such as glaucoma and macular degeneration. Our doctors recommend that all patients over the age of 40 have a baseline screening performed and also recommend a screening for any patient over the age of 30 who has a family history of glaucoma or macular degeneration.

Make a selection

Please provide your initials to acknowledge the information and/or consent for eye health screenings:*