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Home » Contact Us » Patient Medical History Forms » Online Patient Registration Form

Online Patient Registration Form

Personal and Medical Background Information Form

  • The NEW Daytona Optomap Retinal Examination is prescribed by Dr. Roth to evaluate the health of your retina (back part of the eye). It produces a sharp and wide view of your retina, without using eye drops. The advantages to you are:
    1. Fast (less than 1 second per eye).
    2. No blurred vision afterwards.
    3. You will see the back part of your own eye, and the doctor will explain the findings.
    4. This is now part of your permanent record, so we can then compare the retina from year to year.
    This new technology is a part of our standard of care and the fee for this test is $39.00. This test is not covered by any medical insurance.
  • Addresses eye health and eyeglass prescriptions.
  • There are 3 levels; standard, complex, and custom. The fee for this service is separate from the comprehensive examination.
  • This service (1) assesses the fit, positioning, power, corneal health, etc. with your contact lenses on, and then (2) assess your cornea and prescription (refraction) after removing your contact lenses. This additional testing is separate from a Comprehensive Examination. The fee for this assessment starts at $25.00.
  • Brief Questionnaire

  • Example: Near work such as reading, crosswords, cards, crafts.
  • Example: Basketball, Golf, Swimming, Tennis, Racquetball, etc.
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Telemedicine
Teletherapy @ Home!

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Dear Valued Patient,

At Family Eye Care, the health and safety of our patients and employees is our top concern.

Our office has a long-standing practice of disinfecting all areas of our office throughout the day, and all clinic areas are disinfected prior to every patient seen.

As always during the peak of flu season, and with the growing concerns around the Coronavirus, we have taken extra measures to increase frequent cleaning and have provided additional training and precautions to our staff to help keep their health and yours safe.

As a reminder, if you have fallen ill, have traveled abroad, or had close contact with someone who has traveled abroad within the past 14 days and are due to be seen for an appointment, please let our office know. We will be happy to change your appointment to ensure the safety of our patients and staff.

Feel free to contact us with any questions. Thank you.

Family Eye Care Team