Forms for Existing Patients – Gates Vision Care

Welcome Back to Gates Vision Care

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Name

Date of Birth

Address

City

Zip Code

Phone Number

Email Address

Insurance Company

ID/Last 4 of SS#

ANY CHANGES IN MEDICAL CONDITIONS/MEDICATIONS?

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Medical Conditions:

Medications:

Section

Gates Vision Care uses a Visual Field Analyzer to screen for visual field loss. The test can diagnose glaucoma, tumors, and macular degeneration, among many other disorders.

* Testing is painless and takes about three minutes.
* The fee for this test is $15, which is not covered by your insurance.
* This test is optional.

Radio Buttons

I would like to have the Visual Field Screening.

I understand the importance of the Visual Field Screening, however I decline the test at this time.

Patient Signature/Legal Guardian

Date

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