Patient Information s2

PATIENT INFORMATION

Thank you for choosing our practice for your eye care needs. Please print and complete the form front and back. Once you have completed this form, please return along with your driver’s license and insurance card (if applicable). Today’s Date: ______

Name: ______Title ______Dr. Mr. Mrs. Miss

Nick Name: ______Age: ______Date of Birth: ______

Address: ______City: ______State: _____ Zip ______

Cell phone # ______Work phone # ______Home phone # ______

Social Security # ______Driver’s License # ______

You or your parent’s employer: ______Occupation: ______

Spouse or Parent’s name: ______

E-mail: ______

Preferred method of contact? Please circle: Text Phone call Email

Whom may we thank for referring you to our office? ______

INSURANCE INFORMATION

Vision Insurance ______Health insurance: ______

PERSONAL EYE INFORMATION Check all that apply: Amblyopia Foreign body sensation Sandy/gritty feeling Blurred vision at distance Halos Sensitivity to light Blurred vision at near I experience regular headaches Tired eyes Burning I stopped wearing contact lenses Watery eyes Double vision I stopped wearing glasses Redness Drooping eyelid(s) Infection of eye or lid Loss of vision Fluctuating vision Itching Floaters or spots Eye Pain and/or soreness Loss of peripheral vision Eye Surgery

CONTACT LENS AND GLASSES HISTORY: What brand of contacts do you wear? ______How old are your current contacts? ______How often do you replace them? ______What kind of glasses do you own? Check all that apply Back up pair Safety glasses Sunglasses Distance only Compter Sports glasses Progressive lens Bifocals Reading CONFINDENTIAL

MEDICAL INFORMATION What is your general health? ______Date of your last general health exam? ______Any Abnormalities reported? ______Who is your primary care physician? ______Do you have problems with any of the following/systems? _____ Allergies _____ Arthritis _____ Asthma/Respiratory _____ Cardiovascular _____ Diabetes _____ Ears/nose/throat _____ Endocrine (glands) _____ Gastrointestinal _____ High blood pressure _____ Integumentary _____ Lupus _____ Muscles/bones _____ Nervous _____ Thyroid disease _____ Urinary

Please Explain: ______Other health problems: ______Do you smoke? ______Are you currently taking any medications? ______Type: ______Are you taking any hormones, including Birth Control pills? ______Type: ______Are you allergic to any medications? _____ Explain: ______Have you had any operations? ______Type: ______When? ______

FAMILY HISTORY

Does anyone in your family have a history or the following? _____ High Blood Pressure _____ Diabetes _____ Glaucoma _____ Macular Degeneration _____ Cataracts _____ Heart Disease _____ Wear Glasses _____ Eye Disease _____ Wear Contact Lenses _____ Tuberculosis _____ Blindness _____ Turned or Lazy Eye

CERTIFICATION AND ASSIGNMENT To the best of my knowledge, the above information is complete and correct. I understand that is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

I certify that I, and/or my dependent(s), have insurance coverage with ______Name of Insurance Company And assign directly to Eye Care Associates all insurance benefits for services rendered. I understand that I am financially responsible for all charges not covered by insurance, as well as, any copayments at the time of the visit. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year form the date signed above.

______Signature of Patient, Parent, Guardian or Personal Representative Date

______Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient