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Welcome toFamily Eye GroupMichael R. Pavlica, MDDiseases & Surgery of the Retina& Vitreous, Diabetic Eye Disease,Macular Degeneration & MacularHoles, Retinal DetachmentsThank you for choosing Family Eye Group for your eye care. Please review ourwelcome packet and complete the forms on the front and back prior to comingto the office for your first appointment.David M. Armesto, M.D.Cataract & Refractive Eye Care& Corneal/External DiseaseGarry L. Leckemby, ODAlso, please bring to your appointment:Your insurance card(s)Management of Ocular Diseases& Contact LensesDriver’s license or other form of photo IDAnh T. Nguyen, ODA referral form if required by your insuranceManagement of Ocular Diseases& Contact LensesYour insurance co-paymentSigned financial policy form that is included in this packetA list of your medications and the containers for anycurrent eye medicationsPlease contact your insurance company should you have any questions regardingyour coverage. You will be responsible for any balances not covered by yourinsurance plan.Please note that vision plans do not generally cover medical portions of theexam or testing. You or your medical insurance co-pay may be responsiblefor these charges.We look forward to seeing you on at .Please arrive 15 minutes prior to your appointment time so that we may completeany additional information that is needed when checking in.Phone717-299-9232Patient Fax717-299-6532Lancaster OfficeLGH Health Campus2110 Harrisburg Pike, Ste. 215Lancaster, PA 17601Ephrata Office155 North Reading RoadEphrata, PA 17522If you have any questions or are unable to keep this appointment, we ask that youplease give us a call well in advance.We are committed to providing you with the best possible care and look forwardto meeting you.Sincerely,The Doctors and Staff of Family Eye Group

What Happens in aTypical Appointment with aFamily Eye Group Doctor?Upon Arrival:You will be greeted at our front desk where you will be checked in for your appointment. If you are a new patient your completedregistration forms will be collected and this information will be entered into our practice management system. If you are a returningpatient, we will confirm that the information we have on file is accurate and up to date. Your insurance card will also be reviewed to makesure that we have your current insurance information on file.Patient Financial Responsibility (Time of appointment):We will collect any co-pays, co-insurance and deductibles when you check-in. If you cannot pay your co-payment, we will reschedule yourappointment to a later time in the day or to another day. Since your appointment time was scheduled specifically for you, out of respect forour providers and other patients who may have needed your appointment time, we kindly ask that you give our office a 24 hour notice ifyou are unable to keep your appointment. You may be charged for a No Show appointment if you fail to provide a 24 hour notice to informus that you are unable to keep your appointment.Your appointment:An ophthalmic technician will take you from the reception room to a screening room where the technician will:Record your medical history and current symptomsCheck your near and distance vision and eye pressureCheck peripheral vision, eye muscles and pupilsCheck glasses prescriptionDepending upon your symptoms, other tests might be performedAfter the technician completes your screening and testing, your eyes will be dilated and you will be seated in a small waiting area. Thedilation is very important because it makes it possible for the doctor to see the backs of your eyes to assist the doctor in diagnosing yourcondition. After you are fully dilated, the technician will seat you in the doctor’s examination room where the doctor will:Examine your eyesReview your diagnosis with youPrescribe needed medicationsOrder any follow-up testingTell you when you need to come in for your next appointmentAnswer any questions you might haveThis obviously is a very eventful appointment; therefore, you should always plan on being in our office for an extended period of time,sometimes up to two hours. Please remember to bring dark glasses to assist you in seeing following your dilation. Fully dilated eyes maycause you to experience temporary sensitivity to bright lights and sunshine until your pupils return to normal.Please do not hesitate to contact our office at 717-299-9232 should you have any questions prior to your appointment. We lookforward to seeing you!

Medical ReviewOf SystemsPatient NameBirth DateDO YOU CURRENTLY HAVE ANY PROBLEMS IN THE FOLLOWING AREAS?EYESYesLoss of VisionLoss of Side VisionYesYesDistorted Vision or HalosYesFluctuating VisionYesFlashesYesFloatersEye Pain or SorenessYesYesLight SensitivityYesDouble VisionCrossing or Drifting of EyesYesYesRednessDischargeYesYesForeign Body SensationSandy or Gritty FeelingYesYesDrynessYesItchingYesBurningYesExcess LFeverFatigueWeight LossWeight GainYesYesYesYesSKINRashes or Color ChangesItching or DrynessHair or Nail ChangesYesYesYesAdditional Notes/Comments:EARS, NOSE, MOUTH & THROATHearing DifficultyYesRingingYesYesVertigoYesSinus CongestionYesRunny NosePost-Nasal DripYesYesNosebleedsDry Throat/MouthYesYesHoarsenessYesJaw PainCARDIOVASCULARYesChest tness of BreathYesWheezingGASTROINTESTINALSwallowing stipationYesYesNauseaGENITO-URINARYUrinary FrequencyYesYesUrinary Pain or BloodMalesYesDischargeLesions or MassesYesFemalesYesCurrently PregnantBreast MassesYesYesBreast DischargeYesVaginal Bleeding/DischargeMUSCULOSKELETALJoint PainJoint SwellingRednessMuscle PainMuscle TinglingWeaknessParalysisFaintingBlackoutsSlurred yYesDepressionOtherENDOCRINEHeat IntoleranceCold IntoleranceExcessive ThirstExcessive HungerYesYesYesYesHEMATOLOGICALEasy BruisingEasy BleedingBlood TransfusionsSwollen Lymph NodesYesYesYesYesALLERGYSeasonal AllergiesYes

Medical InformationFormPatient’s Name:Birth Date:YesDo you wear glasses or contact lenses?No//If Yes, for how long?yes if any of the following apply to you and thelist thedatedateit firstit L ronchitisCancer – typeCOVID-19Diabetes – typeDiabetes– typeHighbloodpressureHigh blood iseaseHeart InjuryDiseaseHeadHeadInjuryHIVpositive/AIDSHIV positive/AIDSKidneyDiseaseKidney onditionDatePleaseRheumaticFeverYesNoMigraine HeadachesRheumatic resStrokeYesNoStroke / GonorrheaSyphilisYesNoSyphilis /DiseaseGonorrheaThyroidsYesNoThyroids r Medical Problems (PleaseOther Medical Problems (Please List)SURGICAL HISTORYHave you had general surgery?Please list:SurgeryYesNoSurgeon/HospitalDateMEDICATIONS (Please List)NameDosageAre you allergic to any medications, iodine, latex or anesthesia?YesNo If yes, please list below:Do you require antibiotics prior to dental work or surgery?YesNoHave you had eye surgery?YesNoPlease list (including laser and lid surgery):SurgeryDateSurgeon/HospitalFAMILY MEDICAL PROBLEMSDo any family members have: PleaseRelativeGlaucomaYesNoMacular DegenerationYesNoDiabetesYesNoRetinal esNoOther (list):SOCIAL HISTORYAre you pregnant?Do you smoke?Do you drink alcohol?Do you drink caffeine?Do you use illegal drugs?YesYesYesYesYesNoNoNoNoNoThis is to certify that, I the undersigned, consent to examination and treatment. This information and any photography may be used for scientific andeducational purposes. I hereby authorize Family Eye Group to furnish information to my insurance carrier, employer, referring physician, or other physicianconcerning my treatment and/or illness. I transfer assignment of all insurance benefits to Family Eye Group for services, treatment, supplies or surgeriesprovided by physicians or staff. I understand that I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY MY INSURANCE.Patient SignatureDate

Patient RegistrationFormPatient RegistrationFormPATIENT INFORMATION:Last Name:First Name:MI:Birth Date:MI:Birth DaSttea:te:Zip:State:Zip:PATIENT INFORMATION:Aesasm: e:Ladsdt rNCity:First Name:HdodmreesPsh: one:ACietyll:Phone:CEmaiel Adodnrees:s:HomPhACgelel EmcpOculopyaetrioAnd: dress:Employer:City:Musd:ress:Emapriltoayl eSrtaAtdSingleSpouse’sMarital StBirthatus: Date:SingleMarriedWidowedSpouse’s Birth Date:WidowedMSocial Security #Employer SPohcoinael :Security #FEmployer PhoneS: tate:Zip:State:Zip:SCpitoyu: se’s Name:DivorcedSpouse’s Social Security #:MarriedFMDivorcedSpouse’s Social Security #:Spouse’sEmployer:Spouse’s Name:Phone Number:Spouse’s Employer:Phone Number:PLEASE COMPLETE IF PATIENT IS UNDER AGE 18 OR A COLLEGE STUDENT:Father’s Last Name:Father’s First Name:MI:Father’s Birth Date:PLEASE COMPLETE IF PATIENT IS UNDER AGE 18 OR A COLLEGE STUDENT:atthoyaemr:e:FFaheerr’’ss ELamspt lNateh:er’s Employer Phone: MI:Father’s First NaFmatthheddFFaerr’’ss AEmprloeysse:r:CFaittyh:er’s Employer Phone:Father’s Birth Date:State:FFaerr’’ss AHdomatthhedreesPsh: one:Father’s Cell Phone: City:Fathers’ Social SSetacuter:ity #:Mst oirnset :Name:FatheMr’soCMIF: athers’ MSooctihael rS’seBcuirrtihtyD#a:te:Mootthheerr’’ss LEamspoyaemr:e:Mt lNoteh:er’s Employer Phone:MI:Mother’s First NMamMddMootthheerr’’ss AEmprloeysse:r:Ciotyth: er’s Employer Phone:MZip:Zip:Mother’s Birth Date:State:Mootthheerr’’ss AHdodmreesPsh: one:MMother’s Cell Phone:City:Mother’s SocialSStaetceu:rity #:Mother’s Home Phone:Mother’s Cell Phone:Mother’s Social Security #:Zip:Zip:REFERRAL INFORMATION:Name of Optometrist:Name of Family Physician:REFERRAL INFORMATION:WereNameyouof Oreferredptometriherest: today by any of your physicians? If so, whom?:Werereferredhere todayby anyof your physicians?If so, whom?:Is the youreasonfor today’svisit dueto Workman’sCompensation?Name of Family Physician:q Yes q NoIf yes, please complete Workman’s Comp Insurance section on(Pleasethe nextpage. back side)complete(Please complete back side)PLEASE COMPLETE BACK SIDE

MEDICARE PATIENTS WHO HAVE PART B:Medicare Number:Effective Date:1. Do you or your spouse work for a company that provides you with health insurance?YesNo2. Are you entitled to Medicare because of disability or End-Stage Renal Disease?YesNo3. Is the illness or injury the result of an automobile accident or other injury?YesNo4. Has the treatment for the accident or illness been authorized by the Veteran’s Admin?YesNo5. Are you entitled to any benefits under the Federal Black Lung Program?YesNoPRIMARY INSURANCEName of Insurance:ID Number:Employer:Group Number:Who is the subscriber:Do you need a referral?:Subscriber’s Date of Birth:Subscriber’s Social Security #:YesNoSECONDARY INSURANCEName of Insurance:ID Number:Employer:Group Number:Who is the subscriber:Do you need a referral?:Subscriber’s Date of Birth:Subscriber’s Social Security #:YesNoWORKMAN’S COMP. OR AUTO INSURANCE:Where should bill be sent?:Address:Claim or Policy Number:Patient Name:Today’s Date:Phone Number:City:State:Date of Injur y:Date of Birth:Zip: