New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Maynard, Gretchen L Dr. C/L Teach, Dr. Streiff, Lavender Dr. Galina, Nikolova V	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Miss

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None BLUE CROSS BLUE SHIELD COMMUNITY VISION CARE EYEMED VISION ILLINOIS PUBLIC AID MARCH VISION CARE MEDICARE NO INSURANCE PRIVATE INSURANCE UNITED HEALTH CARE VISION CARE PLAN VISION SERVICE PLAN
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None BLUE CROSS BLUE SHIELD COMMUNITY VISION CARE EYEMED VISION ILLINOIS PUBLIC AID MARCH VISION CARE MEDICARE NO INSURANCE PRIVATE INSURANCE UNITED HEALTH CARE VISION CARE PLAN VISION SERVICE PLAN
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None BLUE CROSS BLUE SHIELD COMMUNITY VISION CARE EYEMED VISION ILLINOIS PUBLIC AID MARCH VISION CARE MEDICARE NO INSURANCE PRIVATE INSURANCE UNITED HEALTH CARE VISION CARE PLAN VISION SERVICE PLAN
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Medical History

Medical History: Diabetes, High blood pressure, Heart Disease, Thyroid Disease, Kidney Disease, Arthritis, Asthma, Cancer, Stroke, Seizures, Heart Condition, Other

Good Health DiabetesHigh blood pressureHeart DiseaseThyroid DiseaseKidney DiseaseArthritisAsthmaCancerStrokeHeart ConditionHIVHTNHx of Drug/Alcohol AbuseSeizuresSeizuresSeizuresInflammatory Bowel DiseaseLupusSeizure DisorderOther

Ocular History: Glaucoma, Macular degeneration, Cataract, Retinal detachment, Crossed/lazy eye, Injury, Surgery

*None Allergic ConjAmblyopiaBlepharitis CataractsFloatersGlc suspectMacular DegenerationNTGPOAGStrabismus

Injuries, Surgeries, Hospitalizations:

*NoneInjuryHospitalization Surgery

Family Medical History:

Good health Arthritis Asthma Cancer Diabetes Heart Condition HIV HTN HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Kidney disease Lupus Seizure Disorder Stroke Thyroid Disease

Family Ocular History:

None Glaucoma Macular degeneration Cataract Retinal detachment Crossed/lazy eye Unknown

General Practitioner:

Pregnant/Nursing:

*No Yes Unsure

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Medications (Prescribed):

*NoneActosAcyclovirAdderallAlbuterolAllegraAltaseAmarylAmiodaroneAmoxycillinAtenololAugmentinBactrobanBusparCaptoprilCarbamazepineCefzilCelebrexCiproClonidinCoumadinCozarCrestorDepakoteDetrolDiclofenacDilantinDiovanEffexorFlomaxFlonaseFurosamideGlucophageGlyburideHCTZHumulinHydrocortisoneLasixLevaquinLipitorLortabMetforminMethylprednisoloneMC ContinNasacortNovalogOxycodonePepcidPlaquenilPlavixPrednisonePremarinPremproProtonixProventilProzacRitalinSingulairSynthroidTetracyclineTopomaxValiumWellbutrinXanaxZantaxZestrilZoloftOther

Over-The-Counter Medications:

*NoneAcetomenophinAllegraAspirinIbuprofenZyrtecOther

Vitamins:

*NoneACELuteinMultiOmega 3ZincOther

Eye Meds:

*NoneAlphaganArtificial TearsPatadayTravatanVisineXalatanOther

Drug Allergies:

Primary Vision Correction:

*NoneGlassesFTWGlassesDVO GlassesNVO Contacts-SoftContacts-RGP

Last Eye Exam:

*1 year<1 year 2 year 3 years

Sunglasses?

*YesNo

Type of CLs:

*None Soft Sphere Soft toric Soft bifocal RGP-single vision RGP-bifocal

Occupation:

Hobbies:

*None listedArtBaseballBoatingBasketballCookingCraftsDancingDivingFootballFishingGolfGardeningHorseback RidingHuntingModelsNeedlepointNonePaintingPhotographyPianoReadingRunningRollerbladingSoftballSewingSkiingSoccerSwimmingTennisVideo GamesWoodworking

REVIEW OF SYSTEMS-Please document if you currently have or previously had any of the following: CONSTITUTIONAL:

*NoneFatigueFeverNight SweatsWeight GainWeight Loss

EYES:

*NoneBlurDouble VisionFloatersFlashesGlareDistortionTearBurnItchDryRedPainLight Sensitive

EAR/NOSE/THROAT:

*NoneAllergiesSinus ProblemsChronic CoughDry Throat/MouthHard of Hearing

CARDIO:

*NoneHigh BPChest PainIrregular Heartbeat/palpitationsBlood Clot

RESPIRATORY:

*NoneAsthmaBronchitisEmphysemaCOPD

GASTRO-INTESTINAL:

*NoneConstipationDiarrheaHerniaUlcersVomiting

REPRODUCTIVE/URINARY:

*NoneBladder IssuesImpotenceKidney ProblemsUrination-frequentUrination-painful

MUSCULOSKELETAL:

*NoneJoint PainJoint SwellingMuscle PainMuscle WeaknessRheumatoid Arthritis

SKIN:

*NoneAcneEczemaGrowthsRash

NEURO:

*NoneDizzyGait DisturbanceHeadacheMigrainesNumbSeizures

PSYCH:

*NoneAnxietyDepressionInsomnia

ENDOCRINE:

*NoneDiabetesHyperthyroidHypothyroid

BLOOD/LYMPH:

*NoneAnemiabruise/bleed easilyHypercholesterolemia

IMMUNOLOGIC:

*NoneAIDSHIVLupusRheumatoid Arthritis

SOCIAL HISTORY: Race:

*Alaskan NativeAmerican Indian or Alaska Native American Indian/Alaskan Native, Asian Black or African American Black/African American (Not Hispanic) Greek Hawaiian Not Hispanic Greek Hawaiian Hispanic Hispanic or Latino (All Races) Indian More than one race Multi-racial Native American Indian Native Hawaiian or Other Pacific Islander Other Pacific Islander (Not Hawaiian) Other Race Unknown/Not Reported White White (Not Hispanic/Latino)Declined

Ethnicity:

*Hispanic or Latino Not Hispanic or Latino Unknown Ethnicity Declined

Language

*English Spanish Polish Arabic Bulgarian Cambodian Cantonese Central Khmer Chinese French German Haitian; Haitian Creole Hebrew Hindi Italian Japanese Korean Mandarin Portuguese Russian Somali Spanish; Castilian Swahili Thai Urdu VietnameseDeclined

Height: Feet Inches

Weight:

Alcohol:

*No Yes Occasionally Socially

Tobacco:

*never smokerformer smokercurrent every day smokercurrent some day smokersmoker (current status unknown)unknown if ever smoked Yes

Illegal Drugs

*No Yes

Patient Signatures

Medical Insurance Information

PPO Medical Insurance Company Name:
Primary Member Name: Primary Member Date Of Birth:

Financial and Insurance Policies

• All insurance co-pays and deductibles must be paid at or before the time of service. Bensenville Eye Care will submit all pertinent information to my insurance company and help me maximize my insurance benefits as I receive individualized eye care.
• In the event that my medical insurance/secondary medical insurance company fails to pay within 120 days, or if some or all of my balance is applied to my deductible, I understand that I am responsible for the payment of the balance to Bensenville Eye Care. If payment is received from my insurance company after that time, the payment will be forwarded directly to me.
• I certify that the information I have given in reference to my medical insurance/secondary medical insurance is correct.
• I authorize the use of this form for all my insurance submissions.
• I authorize the release of information to all of my insurance companies
• I authorize Bensenville Eye Care to act as my agent in helping to obtain payment from my insurance companies.
• I authorize payment directly to Bensenville Eye Care.
• I permit a copy of this authorization to be used in place of the original.
• If I miss, cancel or reschedule an appointment with less than 24 hours of notice, I understand there will be a $25.00 fee.

Acknowledgements and Consent for Treatment

• I have read and acknowledge the above Financial and Insurance Policies.
• I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
• I consent to the doctor's or designated staff's use and disclosure of any oral, written, or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment, and health care options.
• I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

Patient Name: Date:
Patient's Signature (or Parent/Guardian):

Acknowledgement of HIPAA Receipt

I acknowledge that I received a copy of Bensenville Eye Care's Notice of Privacy Practices.

Patient Name: Date:
Patient's Signature (or Parent/Guardian):

Informacion de Seguro

Nombre de la compania de seguro medico PPO:
Nombre de miembro primario: Fecha de nacimiento del miembro primario:

Politicas Financieras y de Seguros

• Todos los copagos y deducibles del seguro deben pagarse en el momento del servicio o antes. Bensenville Eye Care enviara toda la informacion pertinente a mi compania de seguros y me ayudara a maximizar mis beneficios de seguro a medida que recibo atencion ocular individualizada.
• En el caso de que mi seguro medico/compania de seguro medico secundario no pague dentro de los 120 dias, o si parte todo mi saldo se aplica a mi deducible, entiendo que soy responsable del pago del saldo a Bensenville Eye Care. Si se recibe el pago de mi compania de seguros despues de ese tiempo, el pago se enviara directamente a mi.
• Certifico que la informacion que he proporcionado en referencia a mi seguro medico / seguro medico secundario es correcta.
• Autorizo el uso de este formulario para todas mis presentaciones de seguros.
• Autorizo la divulgacion de informacion a todas mis companias de seguros
• Autorizo a Bensenville Eye Care a actuar como mi agente para ayudar a obtener el pago de mis companias de seguros.
• Autorizo el pago directamente a Bensenville Eye Care.
• Permito que se use una copia de esta autorizacion en lugar del original.
• Si pierdo, cancelo o cambio una cita con menos de 24 horas de anticipacion, entiendo que habra un cobro de $ 25.00.

Reconocimientos y Consentimiento para Tratamiento

• He leido y acepto las polizas financieras y de seguros mencionadas anteriormente.
• Autorizo al medico para que realice todo el tratamiento recomendado que haya acordado mutuamente y que emplee la asistencia necesaria para proporcionar la atencion adecuada.
• Doy mi consentimiento para que el medico o el personal designado usen y divulguen cualquier registro de salud oral, escrito o electronico que sea identificable individualmente como mio con el fin de llevar a cabo mi tratamiento, pago y opciones de atencion medica.
• Certifico que lei o me lo leyeron el contenido de este formulario y me doy cuenta de los riesgos y limitaciones que implica.

Nombre del paciente: Fecha:
Firma del paciente (o padre/tutor):

Reconocimiento de recibo de HIPAA

Reconozco que recibi una copia de las practicas de privacidad de Bensenville Eye Care.

Nombre del paciente: Fecha:
Firma del paciente (o padre/tutor):