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Demographics

General Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthdate Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Insurance 1

Insurance Information
Insurance Name:
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:
Birthdate:
SSN:
Employer/School:

Insurance 2

Insurance Information
Insurance Name:
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:
Birthdate:
SSN:
Employer/School:

Insurance 3

Insurance Information
Insurance Name:
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:
Birthdate:
SSN:
Employer/School:

Medical History

PERSONAL HISTORY
The top line questions are required by Federal Law

Race Ethnicity Preferred Language    Height Ft. In.   Weight (lbs.)

Referred By  Date of Last Eye Exam  Last Eye Dr.

Currently Wear Glasses?  Currently Wear Contacts?

Hobbies / Special Visual Needs:   Interested in Refractive Surgery?  Computer Use (Hours/day)?

REASONS for Today's Visit
MEDICAL Complaint #1 VISION Complaint #1
MEDICAL Complaint #2 VISION Complaint #2
MEDICAL Complaint #3
PERSONAL MEDICAL HISTORY - REVIEW OF SYSTEMS

Allergic/Immunologic Endocrine Hematologic/Lymph
Cardiovascular Eyes Integumentary / Skin
Constitutional Gastrointestinal Musculoskeletal
Psychiatric Reproductive
Respiratory
Ears, Nose, Throat: Genitourinary Neurological
Cancer





 
  

Personal Ocular History - additional: 
Current Medications - Please list below or  No Current Medications

Medication - Drug Allergy - Please list below or  No Known Drug Allergies (NKDA) 

FAMILY MEDICAL HISTORY Family Eye History:
Family Med History:
SOCIAL HISTORY Smoking Status?  Drink Alcohol?  Use Illegal Drugs?
Please list any additional personal history:

Forms

PLEASE REVIEW THE FOLLOWING OFFICE FORMS You agree that by checking the box and entering initials, you are providing your consent to the use of the Electronic Document and such election constitutes your electronic signature and consent, and you agree to be bound by the terms and conditions in such Electronic Documents to the same extent as you had signed a paper document.

View NOTICE OF PRIVACY PRACTICES
*I have read and understood the NOTICE OF PRIVACY PRACTICES.   * Intial  
View EXPLANATION OF YOUR INSURANCE AND BILLING SUMMARY
*I have read and understood the EXPLANATION OF YOUR INSURANCE AND BILLING SUMMARY.   * Intial  
View SIGNATURE ON FILE, ASSIGNMENT OF BENEFITS, RELEASE OF MEDICAL RECORDS, FINANCIAL AGREEMENT
*I have read and understood the SIGNATURE ON FILE, ASSIGNMENT OF BENEFITS, RELEASE OF MEDICAL RECORDS, FINANCIAL AGREEMENT.   * Intial  

Submit Data

After Completing all Forms Please Submit Data on Final Tab
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