NeuroRehab Eval Paperwork - Elevate Vision Therapy & Rehabilitation

Patient's Name(Required)

First Last

Date of Birth(Required)

Preferred Name

Address(Required)

Street Address Address Line 2 City State ZIP Code

Guardian's Name (If Applicable)

First Last

Phone Number(Required)

Email Address(Required)

Often, the doctors and their staff will communicate with patients and their families by email to get information to you more efficiently. Signing below allows us to exchange information via email when necessary.

Please initial if you are comfortable with receiving correspondence regarding your appointments and vision care by email:

If you are 18 years of of age or older, please indicate who else we are permitted to share medical, scheduling and billing information with:(Required)

Please provide full name, relationship to patient, and phone number.

How did you hear about us?(Required)

Patient Health Information

Please list any medications you are currently taking:(Required)

Please list any allergies you have to medications:(Required)

What neurological event/condition brings you to us today?(Required)

When was your last eye examination with an optometrist/ophthalmologist?(Required)

Do you currently wear glasses or contact lenses?(Required)

Yes, Glasses

Yes, Contact Lenses

Yes, Glasses & Contact Lenses

Today’s examination with the doctor will not include an evaluation of ocular health. Having one’s ocular health evaluated at a yearly eye examination and after any brain injury or ocular trauma is important. You are welcome to coordinate that visit with you/your family’s current optometrist.(Required)

Please initial indicating that you have, or will, schedule an appointment for an ocular health evaluation:

Do you experience any of the following: Yes No

Blurred vision?(Required)

Yes

Double vision?(Required)

Yes

Loss of vision (or a portion of your vision?)(Required)

Yes

Headaches or eye strain?(Required)

Yes

Skipping/repeating words/lines when reading?(Required)

Yes

Dizziness or nausea?(Required)

Yes

Poor eye/hand coordination?(Required)

Yes

Light sensitivity?(Required)

Yes

Difficulty with short-term memory?(Required)

Yes

Sleep difficulties?(Required)

Yes

Neurological Event/Condition Information

Please list any medical conditions you are diagnosed with:(Required)

Date of concussion/stroke?

Location of injury/stroke?

For our patients seeing us after a concussion, please answer the following:

Was your injury the result of a car accident?

Yes, my injury is the result of a car accident.

No, my injury is NOT the result of a car accident.

Is your injury part of a workers compensation claim?

Yes, my injury is part of a workers compensation claim.

No, my injury is NOT of a workers compensation claim.

Are you currently enrolled in any other therapies/rehabilitation?(Required)

If so, please let which ones and who you see for these services:

Please list any additional providers you would like us to send a visit summary to.

If you do not want this information release to another provider, please write N/A.

Please authorize us to release your medical information to the providers listed above by initialing here:(Required)

Financial Responsibility:

Your signature below signifies that you clearly understand that Elevate Vision Therapy & Rehabilitation is NOT a member of your insurance plan.

Because the doctor is not on your plan, the expenses for today’s visit will be your responsibility. The estimated cost of today’s visit is $240. This means you will have to pay the doctor’s charges in full at today’s visit. Our office will not file a claim to your carrier. Certain types of plans will not reimburse any money if the patient requests and seeks services from a physician that is not part of the plan or network. Do NOT sign this form unless you completely understand the consequences of your visit, the charges you will have to pay, and the fact that you may not receive any of the money back from your insurance carrier.

I understand all of the above and still want to receive services from the non-participating physician today. I understand and agree to the above Financial Responsibility Policy:

Guardian/Patient Signature:(Required)

Date(Required)

Privacy Information:

The law requires that Clark Optometric Vision Therapy (dba Elevate Vision Therapy & Rehabilitation) make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that I was given the opportunity to read, have read or had explained to me Clark Optometric Vision Therapy’s Notice of Privacy Practice prior to any services offered. I have read and understand this form and am signing it voluntarily.

Guardian/Patient Signature:(Required)

Date(Required)