Patient Forms

At Cascade Family Eye Care, we offer patient forms online so you can complete them in the convenience of your own home or office. Fax us your completed forms or bring them with you to your visit.

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  • Download the necessary form(s) and fill in the required information.

  • Fax us your completed form(s) or bring them with you to your appointment.

Patient Health History Form

Cascade Family Eye Care
Authorization for Disclosure of Health Information

If individual is unable to sign this authorization, please complete the information below:

Cascade Family Eye Care

In order to provide the most comprehensive exam possible we request that all of our patients have a dilated eye exam and/or Optomap imaging. At least 60% of the retina cannot be viewed without dilation. The purpose is to enlarge the pupils to enhance the detection of any ocular diseases such as cataracts, glaucoma, retinal disease, malignant growth, and retinal detachment; all of which can lead to vision loss. In addition, some systemic conditions such as diabetes and hypertension can cause changes in the health of the eye and can be detected by dilation.

​​​​​​​Possible side effects (these side effects typically do not last longer than 4-6 hours):

  • Inability to focus at near

  • Sensitivity to light

  • Blurry distance vision for some patients

  • Mild burning upon instillation

:Induced ocular hypertension: RARE cases have been reported in which redness and sharp pain is experienced because of increased eye pressure. If this happens, contact the doctor immediately.

Cascade Family Eye Care offers advanced ultra-wide field retinal imaging that allows us to view the inside of your eye without the use of dilation drops in many cases. The Optos Optomap allows us to evaluate your retina for problems such as retinal tears, retinal detachments, retinal tumors, macular degeneration, glaucoma, hypertension, and diabetic retinopathy. This scanning system is completely safe for kids and adults and does not emit radiation like an X-ray.

Optomap Benefits:

  • Quick, safe and efficient screening for children and adults, with no side effects

  • In many cases, dilation may not be required

  • Provides you and your family the best standard of care

  • Up to 82% of your retina captured in one scan compared to 15% with traditional imaging

The additional fee of $39 for Optomap imaging is not generally covered by vision or health plan benefits.* The cost is the responsibility of the patient, due at time of service, and can be paid for with a flexible spending account (FSA) or health savings account (HSA).

* If it is a covered benefit, we will submit our usual and customary fee of $75 for reimbursement. *
Please Check One Box:

We require payment in full for services at the time they are provided, except for amounts billed to your insurance carrier(s). We are happy to bill your insurance company for you, but insurance quotes are not a guarantee of payment and you will be responsible for any allowable charges your insurance does not cover. For material such as frames and lenses, we require at least 50% as a down payment before placing an order. We accept cash, checks and most credit cards for payment. There is a $25 charge for NSF checks.

Please be advised that missed or rescheduled appointments in which the office was given less than 24 hours advanced notice, will be subject to a $50 charge.
For those wearing contact lenses, it is our office policy to provide a 3-month window from the time of your comprehensive eye exam to schedule and be seen for a contact lens evaluation. After that 3-month period, we require a full eye exam as your vision can change. It is the patient’s responsibility to comply with clinic policies and provider instructions to finalize contact lens prescription within 3 months of the contact lens evaluation. Contact lens prescriptions are valid for two years after finalization in Washington state.

Would you like to have a fitting for contact lenses?

If individual is unable to sign this authorization, please complete the information below:

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