New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday 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:

Primary

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:
Birthday:
SSN:
Employer/School:

Secondary

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:
Birthday:
SSN:
Employer/School:

Tertiary

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:
Birthday:
SSN:
Employer/School:

Medical History

What is the reason for your visit?
Do you feel your eyes are changing? (if yes, please explain)
Do you have dry eyes or allergies?
When was your last eye exam?
How did you hear about us?
Who was your last eye doctor?
Occupation / Employer:
Hobbies:
How many hours a day do you use a computer?
Preferred Language
Race
Ethnicity
Do you wear contact lenses?
If no, are you interested in contact lenses?
If yes, what type of contacts do you wear?
What brand of contacts do you wear?
How often do you replace your contacts?
What brand of solution do you use?
How long have your contacts been on your eyes?
Do you have any complaints about your current contacts?
Primary Care Physician:
Telephone #:
Fax #:
Please list any surgeries you have had:
Please list any ocular surgeries you have had
List any medications you are taking:
Are you allergic to any medications? (if yes, please list them)
No medicationsno known medical allergiesYes No
Have you ever been diagnosed with any of the following?
smoking status
discuss cessasion
Has anyone in your family ever been diagnosed with any of the following? (if so please state their relationship to you)
Cataracts Macular Degeneration GlaucomaTurned Eye High Blood PressureDiabetes
NOTES/SOCIAL HISTORY

Review of Systems

Do you use tobacco products?
Type:
Amount:
How Long?
Do you drink alcohol?
Type:
Amount:
How Long?
Do you use illegal drugs?
Type:
Amount:
How Long?
GonorrheaHepatitisHIV Syphilis
GENERAL: Fever, weight loss, weight gain, fatigue?
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
ENDORCRINE: Thyroid, Diabetes
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Pain
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
PSYCHIATRIC: Depression, Anxiety, Insomnia
Last Dr Visit:
Reason For Visit:
Injuries, Surgeries, Hospitalization
Vitamins:
Diabetic info:
Controlled?:
Discussed Smoking Cessation

Submit Data / Patient Signatures

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

Please click on the blue underlined link below to view the ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES.

View ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

The law requires that Kara Fedders, OD, P.C. make every effort to inform you of your rights related to your personal health formation. By signing below, I acknowledge that:

I have read or had explained to me prior to any services offered Kara Fedders, OD, P.C.'s Notice of Privacy Practices and agree to continue my care with Kara Fedders, OD, P.C. under said terms.

I was given the opportunity to read Kara Fedders, OD, P.C.'s Notice of Privacy Practices and declined, but wish to continue my care with Kara Fedders, OD, P.C. said terms.

I have read or had explained to me prior to any services offered Kara Fedders, OD, P.C.'s Notice of Privacy Practice and disagree to continue my care with Kara Fedders, OD, P.C. under said terms.

The Notice of Privacy Practices could not be read due to the emergent nature of the care of other reasons describes as:


I HAVE READ AND UNDERTSAND THIS FORM. I AM SIGNING IT VOULUNTARILY.

Patient Signature: Date:

If you are signing as a personal representative of the patient then please indicate your relationship.

Representative Relationship To Patient

SIGNATURE ON FILE FORM

RESPONSIBILITY STATEMENT

Your insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowance or percentages based on your contract with them, not with our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid for by your insurance. We will assist you in receiving your reimbursement as much as possible, but you are responsible in advance for your bill.

FINANCIAL RESPONSIBILITY

By signing this statement you agree to be financially responsible for all charges.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I authorize any holder of medical information about me to release Heath Care Financing Administration and its agents any information needed to determine benefits or the benefits payable to related services. This assignment will remain in effect until it is revoked in writing. A photocopy of this assignment is considered to be as valid as the original.

Patient Signature: Date:

After Completing All Forms Submit Data on Final Tab