REFRACTIVE SURGERY PATIENT EVALUATION

NAME: AGE: DATE: _

OCCUPATION: GLASSES_ CONTACTS_ HARD __ SOFT_

HOW CURRENT IS YOUR EYEGLASS/CONTACTPRESCRIPTION? _

HAVE YOU EVER TRIED MONOVISION? YES NO

MARK ANY THAT ARE APPLICABLE NOW OR HAVE BEEN IN THE PAST:

EYE HISTORY

EYE INJURY/SURGERY(If so, please explain)

MEDICAL HISTORY

DIABETES

HIGH BLOOD PRESSURE

LUPUS/SEVERE ARTHRITIS

KELOIDSOCULAR ll'l"FECTION(especially Herpes Simplex)

RECURRING IRITIS/uVEITIS(red eye with pain)

IKERATOCONUS(thinning of the cornea)

CORNEAL ABRASIONIEROSION

GLAUCOMA

CATARACTS

DIFFICULTY WEARING CONTACTS

DIFFICULTY WITH "DRY EYES"

DIFFICULTY WITH GLAREIHALOS(i.e. driving at night)

(excessive scar tissue formation)

TAKING ANYMEDICATIONS: _

ALLERGIC TOANYMEDICATIONS: _

FOR WOMEN, ARE YOU PREGNANT OR NURSING? _

DO YOU HAVEAPACEMAKER? _

WHAT IS YOUR MOTIVATION FOR CONSIDERING LASER VISION CORRECTION?

OCCUPATION: DO YOU FEEL THAT IT WOULD ENHANCE JOB PERFORMANCE? _

RECREATION: DO YOU FEEL THAT IT WOULD ALLOW YOU TO ENJOY MORE FULLY YOUR SPORTSIHOBBIES?

COSMETIC: DO YOU FEEL THAT YOU WOULD LOOK BETTER WITHOUT GLASSES? _

ECONOMIC REASONS: DO YOU FEEL THAT YOU WOULD SAVE MONEY IN THE LONG RUN ON THE EXPENSESASSOCIATED WITH GLASSES OR CONTACT LENSES? _

ADDITIONALREASONS: _

SIEHT: A FALKENBERG EYE & LASER CENTER I PATIENT INFORMATION

Occupation Have you or your spouse retired from a military career? DYes DNa

Patient Name: Last First Mi. Home Phone # Cell Phone #

Date of Birth Social Security # SexDMaieD Female

Martial Status:D Single D Married D DivorcedD Separated D Widow

State Zip Code

Race:D African American D Asian D Indian D Hispanico Caucasian 0 Native American 0 Other

Address City State Zip Code

Mailing Address (if different from home address) City May we contact you by Email? 0 Yes or DNaEmail Address:

Employer's Name Work Phone #

Spouse / Parent / Guardian Name Relationship to PatientD Spouse D Parent D Guardiano Other

Home Phone # Social Security # Date of Birth

Home Address

Employer's Name Address Work Phone #

Patient's Secondary Insurance Policy Holder's Name

Social Security # Date of Birth Relationship

Social Security # Relationship

Emergency Contact (other then spouse)

Name Relationship

Referred by: Please be specificDr. _

Phone # Other

Name of family member to release health information:

HIPPA DISCLOSURE & INSURANCE AUTHORIZATION/ASSIGNMENT AGREEMENTI hereby authorize this office disclosure of health information and/or to apply for benefits on my behalf for covered servicesrendered. I request payment from my insurance company to be made to the above named provider. I certify that the informationI have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information,including medical information, to other treating physicians and to my insurance company in order to determine Insurancebenefits to which I may be entitled. Either myself or my insurance company at any time may revoke this authorization in writing.Email address used for information only - not shared with others.As of 09-23-2013 this office is compliant with the HIPPA OMNIBUS Rule.

By signing below, I acknowledge that I have read and understand this authorization form.

Signature of Patient or Patient's RepresentativeFORM #BP40442

Date

DATE: _ NAME: _

PRIMARY CARE DO<;TOR'S NAME: Telephone #: _

IPlease review and mark any problems you may have now, or have had in the past 12 months:

Neurological Endocrine Psychiatric Genitourinary General

__ Fainting/Blackouts Diabetes Emotional Disorder Prostate Problems __ CancerIType ___

_ Seizure/Epilepsy __ Thyroid Problems ADD/ADHD Uterine/OvarianProblems Chemo/Date

__ History of Stroke Graves Disease __ Anxiety Bladder Problems Radiation/Date__

__ Migraine Headaches Childhood Illness __ Depression __ Kidney Problems __ STDlType

__ Paralysis Chicken Pox Cardiovascular Gastrointestinal Steroid Usefor:--__ Vertigo __ Mumps __ High Blood Pressure Hiatal Hernia __ Lupus

__ Bell's Palsy Measels Heart Disease/Murmur __ FrequentHeartburn Immune Disease

Alzheimer's __ Diptheria __ History of HeartAttack Ulcers __ Herpes Simplex

__ Downs Syndrome __ Whooping Cough Chest Pain __ HepatitisIType __ __ HerpesZoster/Shingles

Dementia Scarlet Fever __ Angina Liver Problems Sarcodosis

__ Meningitis:BacterialorViral Polio __ Irregular Heartbeats __ Irritable BowelSyndrome Ocular

Parkinson's Respiratory Rheumatic Fever GERD __ MacularDegeneration

Hemato/Lymphatic __ Chronic Cough Pacemaker/Defibrillator Musculoskeletal Glaucoma

Anemia Asthma Ears/Nose/MouthlThroat __ Back Injury Floaters

__ Bleeding Tendency __ Emphysema Sinus Problems __ Neck Injury __ DryEye

__ Hemophilia Tuberculosis __ Loose/Chipped Teeth Herniated Disc Macular Hole

_ Easy Bruising Pneumonia __ FalseTeeth/Caps Rheumatoid Arthritis Retinal Tear orDetachment

Blood Transfusion __ Sleep Apnea Hoarseness __ Osteoporosis

Jaundice Bronchitis __ Difficulty OpeningMouth __ Multiple Sclerosis__ Amblyopia/Lazy Eye

__ OtherlTypeSickle Cell Anemia __ Breathing Problems __ Hard of Hearing __ Fibromyalgia

SARS Tinnitus __ Muscle Pain or CrampsList all (eye) surgeries__

COPD __ Lyme Disease

Family History: Please include which relative was diagnosed:

Glaucoma _ Diabetes _

__ Macular Degeneration _ Other: _

Please turn over and complete the back of this form.

FORM #BP47900

Have you ever experienced any of the following during or after anesthesia? No/Yes Check which apply if yes.

_ High Temperature Jaundice Headache _ Allergic Reaction

_ Delayed Awakening _ ExcessiveBleeding Hoarseness/SoreThroat _ Prolonged Weakness

Muscle Soreness _ Nauseaand Vomiting _ Difficulty with Breathing Tube

Other ~ _

Tobacco Use: No I Former Smoker IYes- Amount/How many packs per day? For how many years? _

Alcohol Use: No liVes - Amount _I

Street/Recreational Drugs: No/Yes-Type? _

Have you ever been tested for AIDS or HIV? No I Yes- Results: _

Have you ever been diagnosed with MRSA? No I YesI

Could you be Pregnant? No I Yes- Start date of last Menstrual Period? __ I__ I__

Height. _ Weight. _

Are you currently/taking Flomax? No I Yes Have you ever taken Flomax? No IYes

Are you allergic tq Latex? No I YesI

Please list all allergies to medications including reaction:

Medication Reaction Medication Name Reaction

Please List all cur~ent medications below:I

Medication Name Dosage How Often Medication Name How Often

I have fully revieJ,ed this questionaire and answered all questions truthfully and to the best of my knowledge. I amaware that my answers could affect my health care, or that of patient for whom Iam responsible.

II

Patient or Responsible Party Signature: x. Date: _

SIEHT: A FALKENBERG EVE & LASER CENTER

FINANCIAL POLICY

SIEHT: A Falkenberg Eye & Laser Center is dedicated to providing the best possible care and service toyou, and regards the complete understanding of this policy as an essential element of your care andtreatment.

As a courtesy, we will bill your insurance. Your insurance is a contract between you and your insurancecarrier. You are responsible for knowing your insurance plan benefits, and obtaining any referral orprecertification (if applicable) before services are rendered. You are required to provide all currentinformation about your insurance to ensure it is up to date allowing proper filing of your claims.

Sel'f Pay Patients who are not insured are required to pay in full at the time of service. The cost for anydate of service is not complete until the finished documentation of that visit is reviewed by our billingdepartment. Any price quoted to you, before your visit or at the checkout desk after your visit is anestimate. We accept Cash, Check, and Money Order and debit/credit MasterCard, Discover, Visa andAmerican Express.

Returned Checks will incur a $50.00 service charge. You will be asked to bring certified funds or amoney order to cover the amount of the check plus the service charge prior to receiving services fromour staff or physicians. If you have any questions, please ask to speak with our Billing Department at540-371-2777 extension 151.

Eye Examinations have two portions, the eye exam and the refraction. The refraction is themeasurement taken to determine if there is a need for glasses and if so, your glasses prescription.Refractions may be done for routine eye exams or medical exams. Not all insurance plans cover allservices. MEDICARE does NOT pay for refractions. If this is a non-covered service under your insuranceplan, you will be responsible for the complete charge. You will be asked to pay $40.00 for the refractionat the time services are rendered in addition to any co-pay your plan may require.

We ask that you keep your scheduled appointments as missed appointments prevent us fromaccommodating other patients. Communication about canceling your appointment is important and weask for 24 hour prior notice. The practice reserves the right to charge a $35.00 missed appointment feewithout proper notification. If you have missed a total of three appointments we reserve the right todeny another appointment for you.

FORM FEES: Completing insurance forms, copying of medical records, filling out disability and DMVetc.require time away from patient care for our staff and Doctors. There will be a $10.00 Administrative feefor filling out forms or copying medical records. There will also be a charge of $.50 per page for first 50pages and $.25 per page thereafter. You will be required to sign a records release prior to receiving yourmedical record. The practice requires 2 business days to gather and prepare Medical Records or fillingout any forms to leave the office.

I acknowledge that I have read and understand these pclicies and authorizations.

PATIENTIRESPOSIBLE PARTY SIGNATURE: Date:

FORM #BP50124

~SIEHT: ~ A FALKENBERG EYE & LASER CENTER

12 Chatham Heights Rd., Suite 100, Fredericksburg, VA, 22405Tel: 540-371-2777 Fax: 540-371-0922

REFRACTION FEE - $40I

The refraction is the portion of your eye exam that measures your ability tosee an object at a specific distance. From the exam chair you look through aPhoropter toward an eye chart. The Phoropter contains lenses of differentstrengths and types that can be moved into view. Our technicians or doctorswill ask you which view is clearer as they place different lenses in front of theeye (lfbetter one or two"). When you are able to read the chart clearest, thetechnician or doctor will make note of the lenses used. The process takes timeand patience due to the interaction required for the most accurate outcome.Refractions are not just for an eyeglass prescription, although a newprescription is often the product of the refraction. The refraction is a criticalpart of any examination. It helps the doctor determine whether your vision isreduced by a medical disease (such as cataracts, macular degeneration, etc). Italso helps the doctor follow the progression of cataracts and other conditions.

Refractions have always been a NON-COVEREDservice under the MEDICAREprogram. OTHERINSURANCEand secondary plans may vary depending onyour individual benefit coverage. In our experience, unless you have routinevision benefit coverage on your insurance, they will NOT cover the cost of therefraction. This fee is due at time of service. If you have a refraction, the $40refraction fee will be collected today at the check-out counter.