dr mark bunde fairway eye center leawood kansas

New Patient Registration

Thank you for choosing Fairway Eye Center. We feel privileged to be able to provide your eye care needs. Our highly trained staff is always ready to answer any questions you may have. We sincerely hope that your visit to our practice will be enjoyable!

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PATIENT INFORMATION:

Salutation

First Name*

Last Name*

Preferred Name/Nickname

Date of Birth*

Month

Day

Year

Social Security #*

DL #

Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone

Work Phone

Email*

How do you prefer to be contacted?*

Which location is your appointment?*

Marital Status?

Patient Employer / School*

Occupation*

How did you hear about our office?*

Referred by*

Please enter your race*

Are you the patient or responsible party for a minor?*

RESPONSIBLE PARTY:

Name of Responsible Party (if minor)*

First Last

Relationship to Patient*

Date of Birth*

Social Security #*

Address (if different)

Street Address City State ZIP Code

Phone (if different)

Name of Employer

Business Phone

Do you have vision insurance?*

Do you have medical insurance?*

VISION INSURANCE:

Vision Insurance Carrier*

Vision Insurance Policy #*

Vision Insurance Subscriber Name*

Policy Holder Date of Birth*

Policy Holder Social Security #*

MEDICAL INSURANCE:

Medical Insurance Carrier*

Medical Insurance Policy #*

Medical Insurance Subscriber Name*

Medical Insurance Subscriber Date of Birth*

Medical Insurance Subscriber Social Security #*

PATIENT OCULAR HISTORY:

Please check all that apply.

Blindness

Cataracts

Crossed Eyes

Glaucoma

Macular Degeneration

Retinal Detachment

Burning

Dry Eye

Redness

Itchiness

Watery Eyes

Headaches

Glare or Halos

Flashes of Light

Sensitivity to Light

Fainting or Dizziness

Mucous Discharge

Soreness/Pain

Eye Strain

Blurry Distance Vision

Blurry Intermediate (Computer) Vision

Blurry Near Vision

Trouble Seeing at Night

Gritty Feeling in Vision

Objects Floating in Vision

Double Vision

Sudden Loss of Vision

Date of last vision exam

Do you currently wear glasses?*

If yes, please bring them to your appointment.

How old are they?

Do you currently wear contacts?*

If yes, please bring them to your appointment

Do you replace your contacts as recommended?*

What kind of contacts do you wear?*

What is your cleaning solution?

Have you had Lasik surgery?*

When?*

Have you had cataract surgery?*

When?*

PATIENT MEDICAL HISTORY:

Please check all that apply

CONSTITUTION

Sudden Weight Gain

Sudden Weight Loss

GENITOURINARY

Kidney Disorder

Pregnant

ENDOCRINE

Thyroid

Diabetes

Type

CARDIOVASCULAR

High Cholesterol

High Blood Pressure

Heart Pain

Stroke

MUSCULOSKELETAL

Arthritis

Joint Pain

Muscle Pain

PSYCHIATRIC, Please Describe

EAR/NOSE/THROAT

Seasonal Allergies

Sinusitis

Dry Throat/Mouth

NEUROLOGICAL

Frequent Headaches

Migraines

Seizures

RESPIRATORY

Asthma

Bronchitis

Emphysema

If you have any medical conditions please let us know when it was diagnosed and the doctor you see for treatments

PATIENT MEDICATIONS:

Do you have any allergies to medications?*

Please list what you are allergic to*

List any medication you take (including birth control, aspirin, over the counter medications and home remedies)

SOCIAL HISTORY:

This information is kept strictly confidential. However you may discuss this portion directly with the doctor if you prefer.

Do you use tobacco products?*

How long and how often?*

Do you drink alcohol?*

How often and what amount?*

LIFESTYLE QUESTIONS:

Do you...

Have only one pair of glasses

Have uncomfortable glasses

Prefer not to wear glasses at times

Wear bifocals

Want information on no-line bifocals

Want information on thinner, lighter lenses

Work on a computer for long periods of time

Spend a lot of time outdoors

Find a need to wear prescription sunglasses

Have difficulty seeing while driving

Have difficulty seeing at night while driving

Require safety glasses

Want more information about corrective vision surgery

FAMILY OCULAR/MEDICAL HISTORY:

Please check all that apply. If checked, a box will appear where you can note the family member.

Blindness

Cataracts

Crossed Eyes

Glaucoma

Macular Degeneration

Retinal Detachment

Arthritis

Cancer

Diabetes

Heart Disease

High Blood Pressure

Kidney Disease

Lupus

Thyroid Disease

Multiple Sclerosis

Other Disease

Family Member with Blindness:*

Family Member with Cataracts:*

Family Member with Crossed Eyes:*

Family Member with Glaucoma:*

Family Member with Macular Degeneration:*

Family Member with Retinal Detachment:*

Family Member with Arthritis:*

Family Member with Cancer:*

What Type of Cancer?*

Family Member with Diabetes:*

What Type of Diabetes?*

Family Member with Heart Disease:*

Family Member with High Blood Pressure:*

Family Member with Kidney Disease:*

Family Member with Lupus:*

Family Member with Thyroid Disease:*

Family Member with Multiple Sclerosis:*

Family Member with Other Disease:*

Please Describe Condition:*

Doctor Recommendations for Your Visit

Retinal Photos*

Digital images of your eyes help assess the health of your retina to detect eye and health conditions such as glaucoma, diabetes and macular degeneration. Early detection is critical to potentially preventing serious disease progression and even vision loss. Images, compared side-by-side, year after year, discover even subtle changes and help to monitor your health. This cost of this screening is $34.00 for both eyes.

Decline

OCT (not available at Raytown, MO location)*

This scan of your retina allows us to detect early signs of ocular conditions including macular degeneration and glaucoma, which can significantly decrease the chance of your eyesight being permanently affected. It can also help us monitor changes due to high blood pressure, diabetes, corneal disorders and determine the cause of floaters. Generally, the OCT and the retinal photos are sold in combination to produce a comprehensive evaluation of the retina, macula, and optic nerve. The total cost for both OCT and Retinal Photos is $50.00.

Decline

N/A

Dilation*

In order to perform a complete exam of the retina and the back of the eye, your optometrist strongly recommends the use of dilation. This may reveal the presence of a serious systemic condition as well as other ocular conditions. Dilation changes near vision for a short time, which varies from person to person and may make bright lights bothersome. This is included in your routine eye coverage at no additional charge.

Decline

Are you currently pregnant or nursing?

Yes

I don’t know

Certification and Assignment

Please read and check to agree*

To the best of my knowledge, the information submitted in this form is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my child, ever have a change in health. I certify that I, and/ or my dependent(s), have insurance coverage or otherwise billable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

NOTICE OF PRIVACY PRACTICE

THIS NOTICE DESCRIBE HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required by law to maintain the privacy of your health information, to follow the terms of this notice, and to provide you with the notice of its legal duties and privacy practices with respect to your health information. We will not use or disclose medical information about you without your written authorization, except as described in this notice. How We May Use or Disclose Your Health Information We will protect the privacy of your health information. The law permits us to use or disclose your health information for the following purpose: Treatment, Payment, and Regular Health Care Operation - Information obtained by us will be used to dispense and provide prescription ophthalmic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request. As and When required by law- We may use and disclose your health information to Public Health Officials, Law Enforcement, Health Oversight Activities (for audits, investigations, etc.), Judicial and Administrative, Deceased Person Information., Worker Compensations programs, Food & Drug Administration (FDA for reporting of adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the military or a veteran of the armed forces when requested, of if you become an inmate in a correctional facility. Personal Communication- We may contact you to provide appointment reminders, annual eye examination cards, and other information about treatments alternatives or other health-related benefits and services that may be of interest to you as well as communicate with individuals involved in your care or payment for your care. Disclosures to Our Business Associates- There are some services provided by us through contracts with business associates. When these services are contracted for, we may disclose health information about you to our business associates so that they can perform the job we have asked them to do and bill you and your third-party payer for service rendered. To protect your health information, we require the business associates to appropriately safeguard the health information. Victims /Abuse, Neglect, or Domestic Violence- We may disclose your health information to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. Marketing Communication. We must obtain your written authorization prior to using your health information to send you any marketing materials. We may communicate with you about products or services relating to your treatments, care or alternative treatments, or provided without authorization. When We May Not Use or Disclose Your Health Information Except as described in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. You Have the Following Rights With Respect To Your Health Information You have the right to request restrictions on certain uses and disclosures of your health information. To make a request, you must complete the Restriction of the Use of Patient Information Form. We are not required to agree to the restriction that you request. You have the right to inspect and copy your health information as long as we maintain your health information. Your health information usually will include prescription and billing records. To inspect or copy your health information, you must complete the Request to Inspect Medical Records Form. We may charge you a fee for the cost of copying, mailing, or other supplies that are necessary to grant your request that the denial be reviewed. You have the right to request that we amend your health information that is incorrect or incomplete. To request an amendment, you must complete the Request to Amend Medical Records Form. We are not required to change your health information and we will provide you with information about the procedure for addressing any disagreement with the denial. You have the right to receive an accounting of disclosures of your health information we have made after April 14, 2003, for most purposes other than treatments, payment, health care operation, information provided to you, and certain government functions. To request an accounting, you must complete the Request for Accounting of Disclosures Form. You must specify the time period by may not be longer than six years. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time. You may request communication of your health information by alternative means or at alternate location. For example, you may request that health information; you must complete the Request for Alternative Communication Form. Your request must state how or when you would like to be contracted. We will accommodate all reasonable requests. If you wish to exercise one or more of these rights, please contact this office at the above address or phone number. Changes to this Notice of Privacy Practices We reserve the right to amend our practices and this Notice of Privacy Practices at any time in the future and to make the new notice effective for all medical information we maintain. Until such an amendment is made, we are required by law to comply with the notice. The revised notice will be posted in this office and a paper copy will be available upon request. For More Information or to Report a Problem If you have any questions or would like additional information about our privacy practices, you may contact us at the above address or phone number. If you believe your privacy rights have been violated, you may file a written complaint, for which there will be no retaliation, with our form or with the Secretary of Health and Human Services.

Please check to agree to the terms described above*

I acknowledge that I have received the Notice of Privacy Practices

(Type) Signature of Patient, Parent, Guardian or Personal Representative*

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Phone

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Chuck Procner

16:42 21 Nov 21

A very professional, comprehensive eye exam. Dr Nichols took her time and answered my questions completely. Rocky was efficient in his testing and explained what he was doing as well as working to find the most cost effective use of insurance. I would recommend Fairway Eye Center.

Emma

21:07 19 Nov 21

While my experience with my doctor here has always been positive, I cannot say the same for the receptionists. When I’ve called with questions regarding a contacts order or an inquiry about purchasing a pair of frames, even when I’ve called regarding my insurance coverage (standard questions most receptionists should be used to receiving and unbothered about) I’ve been met with consistent rudeness and uppity behavior. I was practically shunned and hung up on when I called about using a third party service to order my contact lenses most recently due to the high costs. I’m disappointed in this treatment and surprised at this behavior. I know these offices are in a very well-to-do neighborhood, but not everyone who needs vision care is wealthy. Treat people with more respect, please. I will be finding another eye doctor if this happens again.

Claude Jacobs

16:07 22 Oct 21

I have been a patient at Fairway Eye Center for three years and have always received exceptional care. The staff is friendly and helpful and I will always trust my eyes to them.

Gabrielle Carrillo

18:11 01 Oct 21

Amazing! Highly recommend.I originally ordered frames and lenses at Mission eye care on Johnson drive. After nearly a month of waiting, I called mission eye care and they tell me my glasses are still not ready and they don’t know when they will be because the lenses were on back order. I was so frustrated with the lack of communication from that other office but I was able to drop my frames off at Fairway Eye Center the same day I called them and my glasses were ready 3 days later! I should’ve went to Fairway first! I will definitely be back! The staff at Fairway were fast, friendly, and professional and I loved the gift bag I received when I picked up my glasses! Thank you so much!

Paula Winchester

18:15 12 Sep 21

After having spent the summer having two cataracts surgeries and many follow up appointments. Many weeks I am very grateful that FEC found an opening for me one morning after I had experienced a throbbing eye throughout the night. Of course, I was quite worried it had to do with the surgeries. Nope, all is good. issue found, and my anxiety alleviated.

New Patient Registration

PATIENT INFORMATION:

RESPONSIBLE PARTY:

VISION INSURANCE:

MEDICAL INSURANCE:

PATIENT OCULAR HISTORY:

PATIENT MEDICAL HISTORY:

PATIENT MEDICATIONS:

SOCIAL HISTORY:

LIFESTYLE QUESTIONS:

FAMILY OCULAR/MEDICAL HISTORY:

Doctor Recommendations for Your Visit

Certification and Assignment

NOTICE OF PRIVACY PRACTICE

Fairway

Leawood

Liberty

Raytown