Patient Forms

Information

Title First Last MI Suffix Nickname Mr. Ms. Dr.

Address:
City:		State/ZipCode	TX

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Divorced Domestic Partner Married Never Married	Employer/School Name

Primary on Insurance Account (Please leave blank if you are the insured)

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

Please continue to the MEDICAL HISTORY tab to finish completing your forms. If you do not press the SUBMIT DATA button on the next tab, we will not receive your form.

Medical History

To save time during your exam, please fill out as much information as possible. Thank you.

CHIEF CONCERN

No vision correctionWears glasses Wears contact lenses

PAST OCULAR HISTORY

GlaucomaMacula/Retinal DiseaseCataracts
Other ocular disease or conditions

Previous ocular conditions, surgeries, injuries, or infections PAST MEDICAL HISTORY DiabetesHigh blood pressureCardiovascular diseaseRespiratory DiseaseHigh CholesterolThyroid Disease Other disease

CURRENT MEDICATIONS

Vitamins and over the counter drugs

ALLERGIES (drugs, seasonal, environmental)(NKDA=no known drug allergies)
To What:

Family Medical History (Please list condition and who)

Family Ocular History (Please list condition and who)

Name of Family Physician Date of Last Exam

Name of Last Eye Doctor Date of Last Eye Exam

Other information

SOCIAL HISTORY
Occupation: Hobbies:

Smoking Status: Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Other What and for how long:

Alcohol: No Yes Occasionally Socially Other What and for how long:

Illegal Drugs: No Yes What and for how long:

STD: None Gonorrhea Syphilis Hepatitis HIV Other

CONTACT LENSES

Please check if you are interested in a contact lens exam.

Currently wear contact lenses?Soft ContactsRigid Gas Perm Lenses

Please check the box if you sleep in your contacts.

Brand Name Right Eye Base Curve Power, including cyl and axis if toric

Brand Name Left Eye Base Curve Power, including cyl and axis if toric

# Hours worn each day

How often do you throw away the contacts?

How often are you supposed to throw them away?

OFFICE POLICIES

By checking this box, I acknowledge that I have read a copy of the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have read a copy of the Notice of Privacy Practices and Patient Consent Form. This allows Eagle Eye Care to conduct normal office procedures in accordance with HIPAA and file insurance claims on my behalf. I acknowledge that I will be financially responsible for any balance not paid by my insurance. A scanned, imaged, typed, electronic, photocopy or stamp of the signatures shall have the same force and effect as an originally executed signature. SIGNATURE / TYPE YOUR NAME Date

Please click the "SUBMIT DATA" button and your information will be electronically sent to our office by a secured website and server. Thank you.

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