Lee Eyecare Center

LEE EYECARE CENTER 9265 E Baseline Rd Ste 102 Christopher E. Lee, OD Mesa, AZ 85209 Linh H Dao, OD (480) 354-4030 Fax (480) 954-4492 PATIENT INFORMATION

Last Name First Name M.I. Sex Date of Birth Age

Address City State Zip Code Home Phone Cell Phone

Email Address:

Name of Member Insured Insured’s ID/SSN Insurance Company Group # / Policy# Employer’s Name

FINANCIAL ACKNOWLEDGEMENT I hereby authorize any person/institution rendering care to furnish all fact concerning this claim. I authorize payment for my vision benefits to go directly to Lee Eyecare Center. I agree that if my employer, insurance carrier or plan sponsor denies payment to all or any portion of my claim, I will be financially responsible for all outstanding charges. Authorization obtained at time of service does not guarantee payment. Signature Date of Service Relationship to Insured  Self  Spouse  Child  Other

PATIENT HISTORY What is the reason for today’s exam?  General Check-up  Eye infection/injury  Want new glasses  Want new contact lenses When was your last exam? ______How old are your present glasses? ______When do you use your glasses or contact lenses?  Constantly  Reading Only  Distance Only

Please Check If The Following Applies To You:

Current Eye Condition Eye Health History  Light Sensitivity  Intermittent Loss of Vision  Flashes or light or  Blurred Distance with present  glasses or  contacts  Eye Injury  Floaters  Blurred Near vision with present  glasses or  contact  Severe Head Injury  Eye surgeries  Blurred near vision without  glasses  contacts  Eye Infection  Retinal Disease  Headaches  Double Vision  Halos or Rainbows near lights  Cataracts  Uncomfortable vision or tired eyes  Distorted Vision  Crossed/ Wandering/ Lazy Eye  Dry Eyes  Usu. Red or irritated eyes  Glaucoma General Health Condition Family History  Heart Disease  Pregnant, how many months? ______ Cataracts  Diabetes  Glaucoma  High Blood Pressure  Retinal Disease / Retinal Detachment  HIV  Macular Degeneration  Allergies  Crossed/Wandering/Lazy Eye  Cancer  Diabetes  Thyroid Problems  High Blood Pressure  Allergic to Medications: ______ Any Inherited Disease? ______ Current Medications ______

Contact Lenses History

 Do you wear Contact Lenses? No Yes, Days per Week:______Last Worn Routinely: ______ Type of contacts last worn: Soft Disposables Gas Perm Manumission Astigmatism/Toric  Method of wear: Daily Wear Extended Wear Flexible/Part Time Wear  Name Brand of your contacts:______ What Lens Care System do you use? Renu Optifree Complete ClearCare Boston Other/Generic______ Have you ever had an eye health problem related to contacts? No Yes, Please explain______ How old are your current Contact Lenses? ______ How often do you replace you disposable Contacts Lenses? Daily 2-3 weeks Monthly Yearly  If you are an extended wearer, how many nights per week do you sleep with them on? ______