LASIK/PRK Consultation

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Affordable Eye Care/ LASIK and Cataract Surgery

Midtown Medical Plaza II R. Stewart Shofner, MD p: 615.340.4733

2021 Church St., Suite 300 Kevin Johnson, OD f: 615.340.4734

Nashville, TN 37203 info@shofnervisioncenter.com

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LASIK/PRK Consultation

How long have you been considering Refractive Surgery (LASIK/PRK)? ☐ 6 months ☐ 1 Year ☐ 2 years

☐ As long as I can remember

Why are you considering Refractive Surgery? (Please check all that apply)

☐ Freedom from contact lenses/glasses ☐ Sports ☐ Occupational ☐ Other: _____________________

Have you had previous eye surgery? ☐ Yes ☐ No If the answer is yes, please explain in detail, giving surgery dates: __________________________________________________________________________

______________________________________________________________________________________

Please review the following, and initial beside each item, indicating you have read and understood them.

Please ask your Surgical Counselor if you have any questions, and sign and date the form below.

_____I understand that Refractive Surgery is not recommended if I am pregnant, nursing, or plan to become pregnant in the next few months.

_____I understand that Refractive Surgery is not 100% predictable; further treatment may be required.

_____I understand that most people require reading glasses in their early 40s (Presbyopia), and that Refractive Surgery does not prevent or cure this.

_____I understand that I will not be able to drive home after surgery, and that I will need to arrange for transportation.

_____I understand that the pre-operative appointment is approximately 2 hours, and may take longer.

_____I understand that the surgery appointment is approximately 2 hours, and may take longer.

_____I understand that if I am taking any of the following medications I must notify the Physician, Ophthalmic Technician, and my Surgical Counselor: Imitrex, Accutane, or Cordarone.

_____I understand that if I am currently, or plan to become a member of the United States Armed Forces, I must notify the Physician, Ophthalmic Technician, and my Surgical Counselor.

_________________________________________ ________________________

Patient Name Patient’s Date of Birth

_________________________________________ ________________________

Signature of Patient or Guarantor Date

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2

Patient Registration

Today’s Date: _______________________

Name: (First, MI, Last) ________________________________________________________________

Date of Birth: ________________ Age: ______ Gender: M ☐ F ☐ Marital Status: S ☐ M ☐ D ☐ W ☐ Address: ________________________________________________ City: ______________________

State: _______ ZIP: ___________ Home Phone: ______________ Work Phone: _______________

Cell Phone: ________________ Email Address: ____________________________________________

Preferred Daytime Contact: H ☐ W ☐ C ☐ Email ☐ Social Security Number: _______-_____-_______

Driver’s License State: ______ Driver’s License Number: _____________________________________

Employer: _________________________________________ Employer Phone: _________________

Employer Address: ________________________________________ City: ______________________

State: _______ ZIP: ___________ Occupation: ____________________________________________

School Name (If full-time student over 18): _________________________________________________

Emergency Contact Name: _____________________________________________________________

Emergency Contact Phone: ________________________ Relation: ____________________________

Primary Care Physician (PCP): _____________________________ PCP Phone: ___________________

Who can we thank for referring you? _____________________________________________________

How did you hear about us? (Please check all that apply) ☐ Google ☐ 107.5 “Woody & Jim”

☐ 94.1 “The Fish” ☐ Facebook ☐ Twitter ☐ www.shofnervisioncenter.com ☐ Bing/Yahoo

☐ Friend/Relative (See referral question above) ☐ Doctor Referral (See referral question above)

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Patient Registration, continued

Guarantor of Account, if different than Patient: ____________________________________________

Address: ________________________________________________ City: ______________________

State: _______ ZIP: ___________ Home Phone: ______________ Work Phone: _______________

Cell Phone: ______________ Date of Birth: ___________ Social Security Number: _____-_____-_____

Primary Insurance: __________________________________________________________________

Name of Policyholder: _______________________________________________________________

Policyholder Date of Birth: __________________ Relationship to Patient: _____________________

Secondary Insurance: ________________________________________________________________

Name of Policyholder: _______________________________________________________________

Policyholder Date of Birth: __________________ Relationship to Patient: _____________________

Other Insurance (Such as Worker’s Compensation, Liability, etc.):

Name of Insurance Carrier: ____________________________________________________________

Case Number: ____________________ Employer Name: __________________________________

Employer Phone: ___________________ Work Comp Case Contact: _________________________

I certify that, to the best of my knowledge, the above information is correct and true. I do understand, however, that I am ultimately responsible for treatment- even if I am here for a Worker’s Compensation visit. I understand that I will be billed for any remaining balance after insurance has paid, and that it is my responsibility to pay this remainder. I further understand that if any insurance denies the claim, I will be billed for the entire balance.

_________________________________________ ________________________

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Patient Registration, continued

I authorize the release of any medical information for the HIPAA approved reasons of TPO- Treatment, Payment, and Health Care Operations. I further authorize release of payment (assign benefits) from my insurance directly to R. Stewart Shofner MD, PC (dba Shofner Vision Center). In the event that I receive a payment from my insurance company in error, I understand that I will be billed by Shofner Vision Center to obtain this payment for services that were rendered to me.

_________________________________________ ________________________

I authorize Shofner Vision Center to notify me via phone call, text, or email for the following:

☐ Yes ☐ No Appointment reminder, by personal or recorded message, or by text.

☐ Yes ☐ No A message to call the office in regards to surgery information.

_________________________________________ ________________________

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5

Notice of Privacy Practice (HIPAA) Acknowledgement Form

I acknowledge that I have received a copy of the Notice of Privacy Practice (HIPAA) for the following entities:

R. Stewart Shofner MD, Kevin Johnson OD, dba Shofner Vision Center.

_________________________________________ ________________________

I authorize ONLY the following individuals to receive information about my health status, which may include protected health information via phone, email, fax, or any other method of communication:

_________________________________________ ______________________________

Print Name of Authorized Individual Relationship to Patient, Date of Birth

_________________________________________ ______________________________

I understand that Shofner Vision Center will only release my protected health information to the individuals listed above. All other requests for protected health information must be made in accordance to Shofner Vision Center’s office HIPAA policy and procedure manual.

_________________________________________ ________________________

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Financial Policy

The goal of Shofner Vision Center is to provide you with the best care possible. Although the costs of medical care continue to rise, we will do all we can to provide affordable care, and work with you financially. Below, you will read a summary of our financial policies. Please review these carefully, initial each item, and sign and date the form.

_____I understand that payment is expected at the time service is rendered, unless other arrangements have previously been made. This includes applicable coinsurance and copayments for participating insurance companies.

_____I understand that cash, personal checks (in-state only), VISA, and MasterCard are accepted for payment.

I also understand that HSA and FSA cards are accepted, provided that they have a VISA or MasterCard logo. I understand there is a $15.00 charge for returned checks.

_____I understand that in-house financing is not available, but I may be offered a chance to finance my care with an application through Care Credit.

_____I understand that I am responsible to cancel an appointment 24 hours prior to the appointment date/time. I understand that if I miss any appointment, other than Post-Op care, I will be charged $25.00.

_____I understand that I will be charged $25.00 for each instance of Disability/FMLA paperwork preparation.

_____I understand that Shofner Vision Center will file my healthcare claims to my insurance on my behalf as a courtesy. I understand that I am responsible for my deductible, copay, and coinsurance. I also understand that if the insurance denies the claim, I may be responsible to contact the insurance company, or to pay the claim in full. I may again, be offered a chance to finance my care with an application through Care Credit.

_____I understand that if I have a credit on my account of less than $20.00, this amount will be retained on the account to be credited toward future balances, unless a written request for the refund is received.

Amounts greater than $20.00 will be automatically reviewed and refunded to the patient/guarantor.

_____I understand that if I am enrolled in a managed care plan (HMO), a referral, or authorization may be required before seeing R Stewart Shofner MD, or Kevin Johnson OD. I understand that this is ultimately my responsibility, and I may be asked to obtain this before treatment. I further understand that I may be responsible for payment if the referral or authorization is not obtained.

I have read and understood the Shofner Vision Center’s financial policy. I agree to assign insurance benefits to R Stewart Shofner MD, PC (dba Shofner Vision Center). I also agree that if it becomes necessary to forward my account to a collection agency for any remaining balance due, I will be responsible for any fee charged by the collection agency for the cost of the collections.

_________________________________________ ________________________

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Medication and Allergy Record

Today’s Date: _________________

Patient Name: ___________________________________________ Date of Birth: _____________________

☐ I have no known drug allergies. ☐ I have drug allergies.

☐ I have no known environmental allergies. ☐ I have environmental allergies.

☐ I have no known substance allergies. ☐ I am allergic to latex.

☐ I am allergic to adhesive tape.

☐ I am allergic to Betadine.

☐ I am allergic to Steroids.

☐ I am allergic to Fluroscein.

Allergy Table

Allergy- Drug or Environmental Reaction

Example Allergy- latex gloves… Severe rashes, itching, and burning…

Medication Table

Please include all prescription and over-the-counter medications such as aspirin, contraceptives, and others.

Medication Name Dose Frequency Comments

Example Med-Valium… 20 milligrams… Once a day-before bed… For anxiety…

***IF ADDITIONAL LINES ARE NEEDED, PLEASE WRITE MEDICATION ON THE BACK OF THIS SHEET.***

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Personal Medical and Ocular History, page 1

Why are you here today? (Please check all that apply) ☐ Routine Eyecare ☐ Contact Lenses ☐ I think I have an infection or injury ☐ Post-Op Follow-Up ☐ I think I have a Cataract ☐ LASIK/PRK Consultation

☐ BOTOX ☐ Other: _____________________________________________________________________

Do you smoke? ☐ Yes ☐ No ☐ Frequency: _________________________________________________

Do you drink alcohol? ☐ Yes ☐ No ☐ Frequency: _____________________________________________

Do you take recreational drugs? ☐ Yes ☐ No ☐ Type and Frequency: ____________________________

Do you drive? ☐ Yes ☐ No

Do you wear contact lenses? ☐ Yes ☐ No ☐ Frequency: _______________________________________

How old is your prescription?_______________________________________________________________

What type of contact lenses do you wear? ☐ Soft Daily Wear ☐ Soft Extended Wear ☐ Toric

☐ Gas Permeable

What brand of contact lenses do you wear? __________________________________________________

Do you wear glasses? ☐ Yes ☐ No ☐ Frequency: ____________________________________________

How old is your prescription?______________________________________________________________

Do you/Have you use(d) prescription eye drops? ☐ Yes ☐ No ☐ Brand: ____________________________

Are you pregnant, or planning to become pregnant? ☐ Yes ☐ No Have you been pregnant in the last 12 months? ☐ Yes ☐ No

Are you currently, or do you plan to become a member of the United States Armed Forces? ☐ Yes ☐ No

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Personal Medical and Ocular History, page 2

Do you currently have problems in any of the following areas?

(Please check all that apply and provide information in the comments section)

Ocular Concern Yes No Comments

Blurred Vision Burning Sensation Crossed Eyes/Lazy Eye Difficulty Driving Distorted Vision (halos) Double Vision

Drooping Eyelid Dryness

Excessive Watering Eye Pain/Soreness Fluctuating Vision Foreign Body Sensation Glare/Light Sensitivity Herpes of the Eye History of “Pink Eye”

Infection Injury/Scar Itching Keratoconus

Loss of Center Vision Loss of Side Vision Mucous Discharge Night Vision Problems Recurrent Corneal Erosion Scratchy Feeling

Tired Eyes

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10

Family Medical and Ocular History

Have you, or a family member been diagnosed with any of the following? (Please check all that apply and provide information in the comments section)

Medical Concern Me Family

Member

Comments

Arthritis Asthma Cancer Cataracts Diabetes Dialysis Glaucoma Heart Disease Hepatitis

High Blood Pressure HIV/AIDS

Implanted Heart Device Kidney Disease

Macular Degeneration Migraines

MRSA

Retinal Detachment Sickle Cell Anemia Stroke

Thyroid Disease Tuberculosis

LASIK/PRK Consultation

Full text

LASIK/PRK Consultation

Patient Registration

Patient Registration, continued

Patient Registration, continued

Notice of Privacy Practice (HIPAA) Acknowledgement Form

Financial Policy

Medication and Allergy Record

Personal Medical and Ocular History, page 1

Personal Medical and Ocular History, page 2

Family Medical and Ocular History

Figure

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