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APPLICANT'S NAME: ___________________________ DATE: _____________________ PREFERRED MAILING ADDRESS: ____________________________________________ ____________________________________________ ____________________________________________ PHONE NUMBER: (____)________________________ EMAIL: ______________________________________ Please supply the following information about your practice as completely and accurately as possible. You may attach additional pages if necessary. Total number of years in practice: ____________ Number of years in practice at current location: ________ Describe your practice setting (town/city population, drawing area, rural vs. urban, etc: Describe your current practice environment (e.g. solo, group, HMO, clinic): In your own words, describe the character and characteristics of your practice and the patients you serve (e.g., socio-economic levels, cultural considerations, optometric orientation, etc.) Please approximate the following specific characteristics of your patient(s) care activity: Age range of patients: ______________________ Number of patient care hours a week in the past year: _____________ Number of patients see per week in the past year: ________________ Percentage of male patients: __________________________________ Percentage of female patients: ________________________________ Percentage of children < 12 years of age: _______________________ Percentage of 13-24 year old patients: _________________________ Percentage of 25-40 year old patients: __________________________ Percentage of 41-64 year old patients: __________________________ Percentage of patients >65 years of age: ________________________ How many auxiliary personnel/paraoptometrists work with you and what are their responsibilities? What type of contact lenses do you fit? What types of binocular vision/accommodative dysfunction/visual perception service do you provide? What types of occupational/sports vision services do you provide? What types of low vision services do you provide? List the auxiliary ocular health testing services/techniques you provide and the frequency with which you perform them. What types of ocular disease treatment and management services do you provide? List the components of a routine eye examination that you would perform on the following patients: 6 years old: 45 years old: 80 years old: Describe any out-of-office patient care activities you perform (vision screenings, hospital-based care, nursing home care, etc): Do you have a formal affiliation with a hospital? If so, what are you responsibilities in this capacity? Do you have clinical privileges, or do you provide care under standing orders? Describe your accessibility to patients after office hours? List the categories of health care professionals to whom you most frequently coordinate additional care needs for your patients. List non-health care professionals, agencies, etc. from whom you have sought consultations for your patients: List the continuing education courses you attended in the last three years: List the journals to which you subscribe: What are your major reference materials? How else do you keep current with new developments in the field? How has your personal type of practice changed since you graduated from optometry school? Please attach samples of: |
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