EyeFinity Eye Care

Pre-Visit Form

EyePM

Pre-visit form

Complete your information before the visit so the office can review your history and contact details.

Helpful to include

Medications, allergies, eye history, and the best phone number to reach you if staff has questions before your visit.

Patient Information

Legal first name *

Legal last name *

Preferred name (optional)

Date of birth

Phone *

Insurance

Sex

Preferred language

Occupation

Race / ethnicity

Parent / Guardian name

Relationship to patient

Street address

City

State

ZIP

Emergency contact name

Relationship

Emergency contact phone

Eye History

Last eye exam

Last medical / physical exam

Your primary / family doctor

Do you wear glasses?

Do you wear contact lenses?

Medications you take regularly

Allergies (medications, latex, foods, etc.)

Health conditions

Past eye problems or eye surgery

Visit Notes

Reason for visit

How did you hear about us?

Additional notes

Consent

Dilation

A dilation exam is highly recommended for symptoms of flashes, floaters, high blood pressure, or diabetes. Additional charges apply.

Yes, I would like to have my eyes dilated No, I do not consent to have my eyes dilated

Visual Field Test

Highly recommended for peripheral vision loss (e.g. glaucoma) or central vision loss (e.g. macular degeneration). Additional charges apply.

Yes, I would like to have the Visual Field Test No, I do not consent to have the Visual Field Test

I consent to receive text messages from EyeFinity Eye Care for appointment confirmations and reminders. Message and data rates may apply. Reply STOP to unsubscribe or HELP for help. This consent is not required to receive services.

Note: Professional fees are non-refundable. Payments are collected at the time of service. An office visit fee will apply for any visits 2 months after the initial exam date.

For insurance patients, all insurance must be presented at the time of service. You are responsible for any services not covered by your plan. I authorize the use of this signature for insurance claims submission.

By submitting this form, I acknowledge that I have been informed and received Eyefinity Eye Care / Thu Kha, O.D.'s Notice of Patient's Privacy Practice.

Signature *

Your signature confirms all information is accurate and that you have read and understood the above policy.

Zoom

100%

Practice Insights

Insights

Practice health at a glance

Patients

Search the roster, spot follow-up needs, and open the full chart for scheduling, prescriptions, and visit history.

6 total · 5 active

Patient	DOB	Insurance	Last visit	Next visit	Date added	Balance	Status	Exams

Insurance

—

Balance

Problem list

No problems on file

Medications / Drops

No medications on file

Linked accounts

No linked accounts

Archive

Search read-only migrated records. Copy a patient to Active when they return to care.

Archive records

Search notes, charts, and imported history

Select an archived patient

Archived records are read-only until activated.

Schedule

Run the day board, review week and month views, and manage appointments, walk-ins, and follow-up work from one place.

⏳ Waitlist

Patients waiting for an earlier slot

Vision Rx

Review the latest spectacle and contact-lens prescriptions, print release documents, and jump back to the source chart when you need edits.

Patient prescription index

Open the latest spectacle or contact-lens prescription by patient, then print or jump back to the source chart when edits are needed.

◎

Select a patient

Prescription details, print actions, and chart links appear here once a patient is selected.

Appointment Requests

Review public requests, match them to current patients, and convert approved requests into scheduled visits without losing context.

New

Awaiting review

Contacted

Needs follow-through

Scheduled

Converted into appointments

Declined / Duplicate

Closed out requests

Select a request

Request details, patient matching, and conversion tools appear here once you open an inbound request.

Autorefractor

Live feed from the in-office NIDEK ARK-1e. Staff assign each measurement to a patient; the doctor pulls it onto a chart with "Import autorefraction".

Loading…

Pre-Visit Forms

Review patient-submitted health history, insurance, medications, and allergies. Create or link to existing patient charts directly from each submission.

New

Awaiting review

Reviewed

Opened by staff

Linked

Matched to a patient

Archived

Closed out

Select a pre-visit form

Patient health history, medications, allergies, and insurance information appear here once you select a submission.

Scan Form

Scan or upload a document

Phone photo, camera scan, or file upload — EyePM reads the form ID and routes it to the right patient chart.

Optical & inventory

Track trial lenses, retail boxes, frames, and order movement while keeping the workflow ready for both contact-lens and full optical practices.

◈

Select an inventory item

Stock details, order activity, and patient-linked optical movement will appear here once you open an item.

Billing & Insurance

Filter:

Select a claim

Coding, payer status, and follow-up details will appear here when you open a claim from the queue.

Reports

Production, revenue, and patient trends drawn from daily logs.

Monthly Revenue

Service Mix

New vs Established Patients

Payment Method Breakdown

Daily Log History

Date	Tech	Patients	Billed	Collected	Write-off	New	Est

SMS Usage

Daily Sends

Type	Count	% of Sent

Autorefractor

How the in-office ARK-1e workflow is performing

Average time to assign

—

Dismiss rate by week

Users

Manage staff accounts, role-based access, and recent sign-in activity so the right people see the right workflows.

Team Members

0 active accounts