pveyes

Alternative text

Which location are you visiting:*

Pearle Vision Chicago (Pulaski Ave) Pearle Vision Countryside Pearle Vision Downers Grove Pearle Vision Evergreen Park Pearle Vision Homewood Pearle Vision North Riverside

Are you a new patient or a returning patient?*

New Returning

Patient Information

Today's Date*

Last Name: *

First Name: *

Age: *

Date of Birth: *

Preferred Name:

Parent/Guardian Name (if under age 18):

Address: *

City: *

State: *

Zip: *

Phone number: *

Email: *

We will use phone numbers provided to call patients with reminders for their appointments. The call may be live or pre-recorded.

Employer*

Occupation*

Visual and Medical History

What type of eyewear do you wear? (Check all that apply)

When was your last eye exam? *

Where was your last eye exam? *

Do you or any of your family have any of the following health conditions?

Diabetes

Self Family No History of condition

High Blood Pressure

Self Family No History of condition

Heart disease

Self Family No History of condition

Thyroid condition

Self Family No History of condition

Glaucoma

Self Family No History of condition

Cataracts

Self Family No History of condition

Retinal Disease

Self Family No History of condition

Are you currently being treated for any medical conditions?

Yes No

Do you or have you ever had any eye injuries or eye surgeries? *

Yes No

List of medications*:

List of allergies*:

Do you smoke? *

Yes No

Do you drink alcohol? *

Yes No

Are you currently pregnant*

Yes No

Tell us about you

What type of environment do you work in? (Check all that apply)

How many hours per day are you usually on a computer, watching tv, or using a phone screen? (Check one)

8+ hours 4-8 hours Less than 4 hours

Is there anything else you’d like to share with the doctor regarding your vision?

HIPAA Privacy Notice

This location does not sell your personal information to any third parties. Copies of the HIPAA Privacy Act may be requested. I acknowledge and agree that this location may submit any vision or medical claims to your insurance to receive reimbursement.

Patient Signature or Patient’s Legal Representative*

Date*

Retinal Imaging

Your eyes are a window to your health. Our retinal imaging camera provides an in-depth look at the health of your eyes. It can assist our doctors to identify potential eye or general health issues, such as diabetes, high blood pressure, headaches, strokes. Early signs of these conditions can show on your retina long before you notice any changes in your vision or feel pain. A thorough evaluation of the retina annually is critical to verify your eye is healthy.

Under normal circumstances, dilation drops might not be necessary, but your eye care practitioner will decide if your pupils need to be dilated depending on the health of your eyes. The image capture takes less than a half-second and they are available immediately for you to see your own retina.

OCT

The OCT (Optical Coherence Tomography) is like an ultrasound of the eye, but painless and quick. It takes 10-15 seconds per eye. This advanced technology can help detect potential vision threatening diseases in their initial stages when they are most treatable. More importantly, the doctor can see the layers in your eye that are invisible with traditional eye examination techniques.

These tests are done as an enhancement to the general eye exam. Please initial one option below:

I agree to advanced testing ($49) (OCT/Retinal Imaging) (Highly recommended for patients aged 50 and above for enhanced monitoring) I agree to Retinal imaging ONLY ($34)

These tests are done as an enhancement to the general eye exam. Please initial one option below:

I agree to advanced testing ($49) (OCT/Retinal Imaging) (Highly recommended for patients aged 50 and above for enhanced monitoring) I agree to Retinal imaging ONLY ($34)

These tests are done as an enhancement to the general eye exam. Please initial one option below:

I agree to advanced testing ($49) (OCT/Retinal Imaging) (Highly recommended for patients aged 50 and above for enhanced monitoring) I agree to Retinal imaging ONLY ($25)

These tests are done as an enhancement to the general eye exam. Please initial one option below:

I agree to advanced testing ($49) (OCT/Retinal Imaging) (Highly recommended for patients aged 50 and above for enhanced monitoring) I agree to Retinal imaging ONLY ($25)

The retinal imaging will be done as an enhancement to your exam for $34

I understand the importance of retinal imaging and agree for my exam today

Are you interested in contact lenses or do you need to renew your contact lens prescription?

Yes No

THE COMPREHENSIVE EYE EXAM

Before a person can be fit with contact lenses, a complete medical and refractive eye examination is necessary. This exam is critical to assure the good health of your eyes and to rule out the possibility of any unsuspected, underlying condition that may prevent contact lens use.

ANNUAL CONTACT LENS EXAM

Everyone being fit into contacts must go through the fitting process. By law, a contact lens prescription is valid for only one year. Contact lens prescriptions cannot be renewed without an annual exam. Contact lens exams have a separate charge that is NOT included in your comprehensive exam. Vision insurance will not always cover these charges. There will be NO refund of the exam, fitting, or annual contact lens examination fee.

Fees:

Spherical $80
----------------------------------------------------
Toric $99
----------------------------------------------------
Multifocal/Monovision $110
----------------------------------------------------
Gas Permeable/ Hard Lenses $135
----------------------------------------------------
Speciality Fit $250+
----------------------------------------------------
Scleral Lens $450+
----------------------------------------------------

CONTACT LENS TRAINING SESSION ( First-Time Wearers)

The patient will be provided with personalized instruction concerning the safe care and usage of contact lenses. Upon completion of successful insertion and removal, the patient may begin wearing the contact lenses and we will schedule the first follow-up appointment within two weeks.

FOLLOW-UP APPOINTMENTS

Follow-up appointments are necessary to assure:
1. The contact lenses are fitting and moving well
2. The prescription is providing the best possible vision
3. The eyes are remaining healthy
4. Prescriptions will NOT be written for patients who do not keep follow up appointments. There is no charge for follow-up visits during the first 30 days or first three follow up visits, whichever comes first.

FINALIZED PRESCRIPTIONS

We are happy to provide you with your contact lens prescription upon the completion of the fitting and the prescription is finalized. Once this prescription is finalized, any issues with the lenses will be addressed at a new contact lens fitting, thus the fee will be charged. All trials are considered finalized 60 days after the exam date. There will be no refund for opened or marked boxes of a supply of contacts, custom lenses, or color contacts.

Patient Name:*

Patient DOB:*

Preferred Method to Receive Rx(Check One):*

Print out Email

Email

Patient Signature: *

Date *

Guardian Signature:

Date