Isthmus Eye Care - Current Patient Form

Current Patient Form

At Isthmus Eye Care, our mission is to provide the highest quality eye care services and vision wear, as well as provide care in a friendly and personal environment utilizing the most modern technology. In order to better determine your needs as a patient the following questions will establish what type of vision correction wear would be appropriate for your lifestyle. We understand that no two pairs of eyes are the same and that is why we aim to ensure the highest vision quality for your individual needs.

Please feel free to take a minute to give us a little information so we may process your application in advance. Thank You!

If you have an appointment scheduled, please enter date and time here.

First Name:
Last Name:
Preferred nickname:
Address:
City: State: Zip:
Telephone: Work: Home:
e-mail:

Check any of the boxes that apply to your particular lifestyle:

At the time of your examination, do you PLAN to...
Purchase new eyeglasses?
Purchase a new supply of contact lenses?

Regarding your OUTDOOR lifestyle, do you...
Do a lot of night Driving?
Spend time outdoors in direct UV radiation?
Read outdoors?
Have need to protect your eyes while working?
Have light sensitivity?

Regarding your INDOOR life, do you...
Work on a computer?
Have more than one pair of perscription glasses for multiple tasks?

Regarding your GENERAL life, do you...
Have a sense of fashion and brand awareness that you would like to meet?
Think you might benefit from thinner, lighter-weight lenses?
Have an interest in contact lenses (if not currently wearing)?
Want detailed information on laser vision correction?
Have family members in need of eye care?*
*If so, please ask about Isthmus Eye Care's SHARE THE CARE Program.

If you wear Contact Lenses...
I am not satisfied with my vision and/or comfort.
I have an interest in trying the latest contact lens designs.
I wear sunglasses with my contact lenses.
I would like to leave my lenses in overnight.
I have interest in color-enhanced lenses.

APPOINTMENT CHECKLIST
Be sure to bring the following to your appointment

Glasses
Contact Lenses
Contact Lens Supplies
Insurance Information

Optomap
The Doctors recommend Optomap retinal exams for all patients who have not previously had one, and recommend repeat Optomap for returning patients (at doctor discretion, dilation may be avoided every other year if Optomap is repeated.)

Your Isthmus Eye Care optometrists recommend this Optomap utilization pattern.

1) No previous Optomap? Optomap recommended for baseline along with dilation
2) Previous Optomap captured and dilated health examination completed one year ago? Optomap repeat recommended; Dilation eye drops may be optional
3) Last exam two years ago or more? Optomap and dilation recommended.
4) Optomap and dilation is recommended annually for patients who have a history of eye disease, highly nearsighted eyes, diabetic or vascular health history, previous retinal abnormalities, or symptoms of blurred vision or floaters and flashes

Please click HERE to learn more about Optomap, and then check one of these boxes:
I elect the Optomap at my examination.
I do not have enough information to decide about Optomap at this time.

Please use this space to make any additional comments or to raise concerns regarding your vision, as well as the main reason for your visit:

Policies for payments:
1. Fees for materials such as glasses or contacts are due at the time of order.
2. Isthmus Eye Care does not have financing or payment plans available.
3. Any fees for examinations or materials that are not covered by insurance are due at the time services are rendered.
4. I authorize payment of insurance benefits directly to Isthmus Eye Care, S.C.

By submitting this form you acknowledge the following statement:
I understand the above information is necessary to provide me with eye and vision care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge.