New Patient Paperwork Sr - Eye Rx

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Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name *

First

Last

Preferred

Address *

Street Address

City

State

Zip

Phone Number *

Email Address

Personal Information

Sex

Male

Female

Gender Identity

Date of Birth *

Day

Month

Year

Social Security Number *

(last 4 digits only!)

Race

Ethnicity

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Eye History

Please check off any current conditions you suffer from

I stopped wearing glasses

I stopped wearing contact lenses

Headaches

Glare/Light Sensitivity

Tired Eyes

Amblyopia (lazy eye)

Burning

Dryness

Watery Eyes

Eye Pain and/or Soreness

Foreign Body Sensation

Infection of Eye or Lid

Itching

Mucous Discharge

Drooping eyelid(s)

Redness

Sandy or Gritty Feeling

Strabismus (crossed eye)

Blurred Vision at Distance

Blurred Vision at Near

Haloes

Double Vision

Floaters or Spots

Fluctuating Vision

Loss of Vision

Loss of Side Vision

Glasses History

Do you wear glasses? *

Yes

What glasses do you own?

Single Vision

Bifocals

Safety Glasses

Backup Glasses

Progressive

Trifocals

Sports Glasses

Sunglasses

Other

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

How many inches away, approximately, do you sit from your computer monitor?

Please check off any current conditions you suffer from

I am having problems with my current glasses

There are times when I would rather not be wearing glasses

I have problems with glare

I have problems with night vision

I am allergic to nickel (e.g. frames of glasses)

I don’t have spare set of glasses

My spare glasses have an incorrect prescription

My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses? *

Yes

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

What is your typical wearing schedule? In days per week:

Please check off all that apply to you

I am having problems with my current contact lenses

There are times when I would rather not be wearing contact lenses

I am interested in changing or enhancing my eye color

I am interested in a non-surgical method of vision correction

I am interested in refractive laser surgery

I don't have a spare set of contact lenses

My spare contact lenses have an incorrect prescription

Medical History

When, approximately, was your last eye exam? *

Where did you get your last eye exam? *

When, approximately, was your last physical exam? *

Who is your primary care physician? *

Do you drink alcohol? *

Do you smoke? *

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.) *

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment) *

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.) *

Please list all hospital surgeries you have ever had: *

Please list all prescription and over-the-counter medications you take and for what conditions *

Please list all drug allergies you have *

Please check off any current conditions you suffer from *

I do not have any medical conditions

Chronic fever, unexpected weight loss/gain, fatigue

Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)

Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)

Respiratory problems (eg. Shortness of breath, wheezing, coughing)

Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)

Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)

Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)

Skin problems (eg. Rashes, excessive dryness, growths or lumps)

Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)

Psychiatric problems (eg. Depression, anxiety)

Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)

Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)

Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name *

Subscriber Name *

Relationship to Patient *

Insurance Company Phone Number *

Member Identification Number *

Group Number *

Name of The Subscriber *

Subscriber's Date of Birth *

Day

Month

Year

Secondary Insurance

Do you have secondary insurance?

Yes

Content

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address

Address Line 2

City

Insured's Name

First

Last

Identification Number

Group Number

Insured's Date of Birth

Day

Month

Year

Patient's Relation to Insured

Consent Form (Financial and Privacy Policies)

Please check the box to acknowledge your agreement

Consent for examination and treatment *

I authorize the doctors and staff of the office to perform eye examinations, diagnostic testing, and treatment as medically appropriate.

HIPAA acknowledgement * *

I acknowledge receipt of the Notice of Privacy Practices and understand how my health information may be used and disclosed. (add link)

Financial responsibility acknowledgement * *

I understand I am financially responsible for all charges not covered by my insurance and that verification of benefits is not a guarantee of payment.

Assignment of benefits acknowledgement * *

I authorize payment of medical and/or vision insurance benefits directly to the office and release of information needed to process claims.

Diagnosis based billing acknowledgement * *

I understand that billing of my medical and/or vision insurance will be determined by reason for visit and clinical findings - not by patient preference.

No-show / cancellation acknowledgement * *

I understand missed or late-cancelled appointments may result in a fee not covered by insurance.

Communication consent * *

I authorize contact by phone, voicemail, text, and email regarding appointments, results, billing, and care coordination.

Eyewear and materials policy acknowledgement * *

I understand custom eyewear and specialty lens products are non-refundable once ordered, except as required by law.

Signature *

Date signed *

Day

Month

Year

Comments

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Privacy Policy

Health Information Protection *

I have read and agree to the Privacy Policy

I have read and agree to the Privacy Practices