Patient Forms Patient Forms for Comprehensive Eye and Vision Exams "*" indicates required fields WELCOME Thank you for choosing our office for your eyecare needs! We’re glad to help if you have questions. All Patient Information is Confidential Mr./Mrs./Ms./Dr. Name:* Date:* MM slash DD slash YYYY Address:* Street Address City State / Province / Region ZIP / Postal Code Cell Phone:*Home Phone:Text OK?* Yes No Email: Birthdate:* MM slash DD slash YYYY Patient’s SSN: Employer: Height: Weight: * Male Female Other Marital Status:* Single Married Preferred Method of Communication: Text Email Cell Phone Home Phone Preferred Language: English Spanish Other Race: (optional) American Indian or Alaskan Native Black or African American Native Hawaiian or Pacific Islander Asian Hispanic White Primary Physician/Pediatrician: Preferred Pharmacy: Insurance Information If you are using insurance, we need to copy your medical and vision cards if you have one.We provide treatment for both medical eye conditions as well as comprehensive vision care.Thank you. Primary Member’s Name: Primary Member’s Employer: Primary Member’s SSN: Primary Member’s Birthdate: MM slash DD slash YYYY Please Sign Both the Privacy Practices AND the Payment Information Notice of Privacy Practice I acknowledge that I have read or have had the opportunity to read the Notice of Privacy Practices (available at the front desk).Patient Name (please print): Date: MM slash DD slash YYYY Signature of Patient or Guardian: Payment Information Payment Information - Please read and sign below. Thank you. 1. I authorize you to bill my insurance for any applicable services or products. 2. I understand that payments for non-insured services are due the same day services are rendered. 3. I understand if I have not met my health insurance deductible and I’m receiving medical eyecare that 50% of the bill is due today,and any balance remaining after being processed through insurance will be billed to me.Signature of Patient or Guardian: Date: MM slash DD slash YYYY We are glad to answer any questions regarding your insurance benefits. Thanks! Your Eye Health and Vision are important to us. Our One Vision is Your Vision. Health History Please indicate if you or your family (blood relative only) have any of the following:ConditionDiabetesPatientMotherFatherSisterBrotherDaughterSonHigh Blood PressurePatientMotherFatherSisterBrotherDaughterSonHigh CholesterolPatientMotherFatherSisterBrotherDaughterSonHeart DiseasePatientMotherFatherSisterBrotherDaughterSonKidney DiseasePatientMotherFatherSisterBrotherDaughterSonThyroid DiseasePatientMotherFatherSisterBrotherDaughterSonAsthmaPatientMotherFatherSisterBrotherDaughterSonCancerPatientMotherFatherSisterBrotherDaughterSonArthritisPatientMotherFatherSisterBrotherDaughterSonGlaucomaPatientMotherFatherSisterBrotherDaughterSonCataractsPatientMotherFatherSisterBrotherDaughterSonTurned EyePatientMotherFatherSisterBrotherDaughterSonLazy EyePatientMotherFatherSisterBrotherDaughterSonEye InjuryPatientMotherFatherSisterBrotherDaughterSonEye Surgery: PatientMotherFatherSisterBrotherDaughterSonBlindnessPatientMotherFatherSisterBrotherDaughterSonMacular DegenerationPatientMotherFatherSisterBrotherDaughterSonSeizuresPatientMotherFatherSisterBrotherDaughterSonOther: PatientMotherFatherSisterBrotherDaughterSonHealth History Continued Please Indicate if any of the following apply to you: Frequent Headaches Frequency: (daily, times per week, monthly) Severity: (low grade, migraine, etc.) Smoker Type: (cigarettes, cigars, etc.) Amount: (one a day, pack a day) Allergies to Medications (Please specify) No allergies to medications Please list all medications allergic to: Allergies Please list: Pregnant Due: Complications: Medications you are currently taking -OR- we can copy a list if you have one None Who can we thank for referring you to our practice? Friend: Co-Worker: Referred by other professional: Who? Google Postcard Who? Facebook Insurance Provider Who? Other: Thank you for answering these questions about your eyes to help us serve you better. Do you currently wear glasses? YES (specify below) NO Full Time Reading/Near Work Other: Do you wear contact lenses? YES NO Are you renewing your contact lens prescription today? YES NO UNSURE Do you have difficulty seeing at night? YES NO Do you wear anything to protect your eyes from the sun? YES NO How many hours per day do you use computer/phone/tablet? Do you ever experience:Gritty or sandy sensation? NEVER SOMETIMES FREQUENTLY Itchy eyes? NEVER SOMETIMES FREQUENTLY Itchy eyelids? NEVER SOMETIMES FREQUENTLY Watery eyes? NEVER SOMETIMES FREQUENTLY Eye pain or soreness? NEVER SOMETIMES FREQUENTLY Redness? NEVER SOMETIMES FREQUENTLY MedicationsList your current medications. Δ
