Home Form During Covid-19

Thank you for taking the time to fill out our patient intake form. The Brinton Vision Ocular Analysis is a process focused on YOU, and this intake form represents the first step in that process. As we get to know each other better you will find that our Brinton Vision team is caring, detailed, and thorough as we work alongside you to help you meet your vision goals. Because of this, our form asks you to answer a number of very specific questions about how you use your eyes – we appreciate your providing a complete response to each question. Our patients tell us that this form takes about twenty (20) minutes to complete. Thank you in advance!*

I understand

About you

(optional) Please provide us with a photo so that our staff can know who to expect

Max. file size: 50 MB.

First and other given names (as on government issued ID)*

Family name/surname (as on government issued ID)*

Preferred name or nickname

Date of Birth (as on government issued ID)

Age*

Please enter a number from 15 to 105.

Gender*

Occupation and employer*

Emergency contact information

Emergency contact*

Relationship*

Mobile phone number*

A great deal of information about your overall wellness and ocular health is shared during your Brinton Vision Ocular Analysis. Our patients often mention that they appreciated having a friend or family member participate to provide them with a second set of eyes and ears.

Patients are welcome to bring one guest with them to the office for their initial consultation.

Which search engine did you use?*

Google

Bing

Other

Where did you find us in your Google search?*

Google ad (first result on page)

Google ratings / reviews (map area)

Organic results (below the map)

Not sure

Do you recall what phrase you searched in Google? (optional)

Visual aids for poor eyesight

Which best describes the prescription lenses you use?*

Prescription glasses only

Mostly prescription glasses, occasional contacts

Mostly contacts, occasional prescription glasses

Contacts only

Do not wear prescription glasses or contacts

How old were you when you first put on prescription glasses?*

Please enter a number from 1 to 105.

Have you ever worn contact lenses in the past? Whether yes or no, please explain.*

We would like to get a sense of how dependent you are on glasses/contacts to see. Assuming 17 waking hours in a day, for how many of these waking hours do you depend completely on prescription glasses/contacts to see?*

How do you read print up close / within arm's reach?*

Use readers

Use readers, but only when wearing contacts

Take off my glasses to read

None of the above - no issues with reading

What power of readers do you use?

At what age did you start using readers or taking off glasses to read?*

We would like to get a sense of how dependent you are on reading glasses to see. Assume 17 waking hours/day. In your average day, for how many waking hours do you depend on reading glasses for near/reading vision?*

How old were you when you first used contact lenses?*

Please enter a number from 1 to 105.

Optional comments on why you prefer one lens type over another. Have you used glasses, contacts, or readers at different times in your life or for different circumstances?

It's not fair that some people have to go through life with a prescription – our procedures level the playing field.

About your glasses

How old is your glasses prescription?*

a few months old

about a year old

less than 3 years old

more than 3 years old

Describe positives and negatives of your glasses-aided vision*

Can you wear or bring these glasses to your BVOA appointment?*

Yes

No

--> It is helpful in the treatment planning process to have your current glasses and test you in them.

If you have numbers from a glasses prescription, please enter them here. Include add power for bifocals, progressive bifocals, or trifocals if you wear these.

Presbyopia occurs in your forties or fifties when you lose the ability to read up close. Our procedures for presbyopia patients are designed to restore everyday, "walking around" reading vision so you can see your watch, dashboard, cell phone, and restaurant menu again without glasses. Our procedures do not replace magnification for professional level, detailed near tasks; patients may still use a magnifying glass or reading glasses. Talk to your Brinton Vision doctor about your near vision needs. Patients over forty encounter trade-offs with all modes of vision correction, whether they wear glasses, contacts, or have surgery.*

I understand

You just left your house for work and discovered that you forgot your reading glasses.*

I would have to turn around and return home to get them to make it through a work day

I would be just fine without them

You just boarded a flight for a weeklong vacation and discovered that you forgot to pack reading glasses.*

I would have to go to the store and buy readers to make it through vacation

I would be just fine without them

About your contact lenses

How old is your contacts prescription?*

a few months old

less than a year old

less than 18 months old

more than 18 months old

Do you wear special contacts to help with your near vision?

Multifocal contacts

Monovision contacts

None of the above

With monovision contacts, which eye is set for distance and which is set for near? When does monovision work well or not work well for you?

Describe positives and negatives of your contacts-aided vision*

Can you bring your contact lens boxes or unopened lenses to your BVOA appointment?*

Yes

No

--> It is helpful in the treatment planning process to have your current contact lens prescription information.

(Optional) Picture of your contact lens foil, side of box, or eye prescription showing numbers

Max. file size: 50 MB.

You may also enter your contact lens prescription numbers here.

Have you previously had LASIK or any other vision correction procedure?*

Yes

No

My vision challenges

For patients age 15-39, which vision problem do you have?*

MYOPIA (nearsightedness). Up close I can see my cell phone and other near items. Street signs and far away print are blurry. My prescription starts with a minus (-) sign.

HYPEROPIA (farsightedness). I can see far away in the distance okay without my glasses, but I sometimes get headaches or eyestrain, especially with up close reading. My prescription starts with a plus (+) sign.

Everything is blurry or not sure

For patients age 40 and up, which vision problem do you have?*

MYOPIA (nearsightedness). I've worn glasses or contacts since I was young. I can see up close but in the far distance my natural eyesight is poor. My prescription starts with a (-) sign.

HYPEROPIA (farsightedness). My vision was excellent until I started to lose reading vision near my 40's. I can't read a restaurant menu anymore, have started to wear readers, and may even need distance glasses or bifocals/progressives. My prescription starts with a (+) sign.

Everything is blurry or not sure

Keratoconus

How is/was the keratoconus treated?*

Glaucoma

How is/was the glaucoma treated?*

eye drops

lasers

glaucoma surgery

I don't know

Dry eye

What dry eye treatments have you used? Which have been successful?*

For your safety, we will need clearance from your primary care medical provider no later than one week prior to having LASIK/vision correction surgery. Written clearance should indicate that your condition has been well-managed and stable for six months and may be on your doctor’s own form or on our form at brintonvision.com/clearance. Your doctor may send by email to [email protected] or by fax to 314-375-2020. Will you be able to obtain this clearance?*

yes

no

not sure

Do you have type I or type II diabetes? Please share last hemoglobin A1c value and date of test.*

Select an autoimmune condition*

Other autoimmune condition

Allergies

Are you allergic to any of the following?*

Tape

Latex

Betadyne/iodine skin prep

None of the above

Do you have any allergies to medications? If so, in what form did you take the medication (pill, IV, injection, eye drop, cream, etc.) and what was your body's reaction (swelling, hives, difficulty breathing, etc.)?*

Your personality

Choose the description that best describes your personality. Medical research indicates that simple self assessments such as this are useful in determining candidacy for certain of our corrective procedures.*

extremely easygoing

usually easygoing

can be a perfectionist

extreme perfectionist

We take pride in meeting and exceeding our patients’ vision goals, even for those with a perfectionistic personality! At the same time, it’s important to have reasonable expectations about what modern laser and lens implant eye surgery can do and what it can’t do. Please take time to share your vision goals and expectations with your doctor at your BVOA.*

I understand

Your general medical care provider

Name and office location of your primary care physician.*

What is the date of your last appointment with your primary care physician?

Your regular eye doctor

Who is your regular eye doctor?*

When was your last exam with your regular eye doctor?

Other eye doctors you have seen

List any other eye doctors you have seen in the past five years

Past LASIK candidacy

Have you ever been told that you are a candidate for LASIK or vision correction surgery?*

Yes

No

List any doctor/facility where you were determined to be a LASIK or eye surgery candidate. How many years ago was this testing completed?*

Which procedures were you offered?*

Questions for Brinton Vision doctor

Do you have any specific questions or concerns you would like our doctors to address?

Yes

No

List questions here

Paying for your LASIK / vision correction procedure

We believe that financial considerations should not be an obstacle to obtaining the clear vision you deserve! Brinton Vision accepts many forms of payment and offers in-house flexible payment options to help make your eye correction procedure fit any budget. Please note our policy that payment in full is required at the time a procedure or exam in our office is reserved/booked. Insurance does not cover laser vision correction procedures because they are not considered a medical necessity.

How do you plan to pay for your care? Check all that apply.

$0 down, 0% interest for 24 months

$0 down & low monthly payments with a fixed interest rate for 60 months

Flex Spending (FSA) funds

Health Savings Account (HSA) funds

Cash, check, or credit card

In our office, in addition to finding out if you are a candidate for LASIK/vision correction surgery, you can also find out if you qualify for flexible payment options. Approximately 95% of our patients qualify. If you have placed a lock or freeze on your credit, remember to have this temporarily lifted prior to arrival. Alternatively, patients may obtain pre-approval for financing, if desired, by clicking one of the following links:

- Alphaeon Credit - "soft" check with no effect on credit score
- GreenSky

Upload any prescriptions or chart notes from previous eye doctor visits

Providing a photograph or scan of the following can be helpful to our team. (optional)
- previous eye records
- any eye prescriptions
- picture of contact lens boxes showing numbers

Max. file size: 50 MB.

Upload a scanned eye prescription or any records

Max. file size: 50 MB.

Disclosures

For internal training purposes only, Brinton Vision may record, with audiovisual equipment, your preoperative exam. This is an important part of our dedication to provide a patient experience focused on you. If you are uncomfortable with this you may opt out here.*

Opt in

Opt out

All individuals are urged to have a yearly dilated eye exam with a qualified eye doctor to ensure the best quality of vision and prevent eye disease. By becoming our patient you agree to follow this recommendation.*

I agree

Please arrive at our office fifteen minutes prior to your appointment time to check in. Late arrivals will be asked to book a new appointment.*

I understand

We routinely coordinate eye care with patients, doctors, and their offices via phone, text, email, and voicemail.*

I understand

We routinely provide medical updates to your doctors and care providers to ensure the highest quality of care. It is often helpful for our staff to review your past eye history prior to your initial visit. Our standard practice is to request this from any eye doctor(s) in our area that you list above. If you want to opt out of this and not have us consider records from a particular doctor, please omit this doctor’s name on this intake form.*

"For a period of one year from the date of my signature below, I authorize and request any optometrist, ophthalmologist or eye care facility that has provided treatment or service to me or on my behalf to disclose/release my medical records including, but not limited to: progress notes, clinical charts, treatment plans/reviews, test results, photographs, medical assessments or records received by other medical providers. I understand that I have the right at any time to revoke this authorization, except to the extent information has been released in reliance upon this authorization. I understand that in order to revoke this authorization, I must do so in writing to Brinton Vision. I understand that I may request a copy of this authorization and that a photocopy is as valid as the original copy. I understand that authorization for disclosure of my protected health information is voluntary and that I may refuse to grant this authorization for any previous doctor by removing the identity of the doctor above. I understand that my electronic signature constitutes my agreement and authorization for release of records as described here."

I understand

You are required to show a driver license or government-issued photo ID for us to scan upon arrival at your first appointment. Your appointment will be rescheduled if you are unable to provide this.*

I understand

By typing my full name below, I affirm and certify that the information and answers to questions herein are complete, true, and correct to the best of my knowledge and belief.*

About you

Emergency contact information

How did you hear about us?

Visual aids for poor eyesight

About your glasses

About your contact lenses

Contact lens habits, risks, and complications

Past eye procedure details

My vision challenges

Past eye history

Keratoconus

Glaucoma

Dry eye

General medical health

Medications and supplements

Allergies

Your personality

Your general medical care provider

Your regular eye doctor

Other eye doctors you have seen

Past LASIK candidacy

Questions for Brinton Vision doctor

Lifestyle

Paying for your LASIK / vision correction procedure

Upload any prescriptions or chart notes from previous eye doctor visits

Disclosures