Pre-Visit Intake | SpectOcular

SpectOcular Pre-Visit Intake

Completed by the patient before the visit · Intake code: · Printed

You're taking the first step.

Every answer you give here becomes part of something bigger. SpectOcular is studying how a photograph of the retina — the back of your eye — might one day reveal early signs of disease elsewhere in the body: the kidneys, the heart, the brain.

That research only exists because people are willing to be first. Thank you for being one of them.

About you

First name

Last name

Date of birth (MM/DD/YYYY)

Phone

Preferred way to reach you

Biological sex

Insurance carrier (optional)

Plan type (optional — pick Unsure if you don't know)

Insurance member ID (optional — from your card)

Street number

Street name

Apartment / suite (optional)

City

State

ZIP

Your primary care doctor (PCP)

First name (optional)

Last name

ZIP (optional)

State

I don't know my primary care doctor — the office will ask at your visit

Search the national provider registry, tap your doctor, and the fields fill themselves — or type them by hand below.

PCP first name

PCP last name

Street number

Street name

City

State

ZIP

Phone / fax (if known)

Your pharmacy

Search by name

City (optional)

State

ZIP (optional)

I don't know my pharmacy — the office will ask at your visit

Search, tap your pharmacy, and the fields fill themselves — or type them by hand below.

Pharmacy name

Phone (if known)

Street number

Street name

City

State

ZIP

Background

Race / ethnicity — check all that apply

Smoking

Weight (lb)

Height — feet

Height — inches

Has a doctor ever told you that you have…

Diabetes?

High blood pressure?

Kidney problems?

If yes — what kind of kidney problem?

Name of the kidney disease, if you know it

Heart and circulation — check any a doctor has told you that you have:None of the below

Brain and nerves — check any a doctor has told you that you have:None of the below

Your answers are sent securely to SpectOcular and held for your visit only — they are reviewed with you in person before anything becomes part of a record. You can re-submit with the same code to correct anything before your appointment. Questions? Contact your eye doctor's office. SpectOcular LLC, Dallas, Texas.