New Patient Form

Demographics

TitleLegal FirstLegal LastMISuffixNickname
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
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 allergies

Have you ever been diagnosed with any of the following?
Cataracts
Macular Degeneration
Glaucoma
Turned Eye
High Blood Pressure
Diabetes

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
Glaucoma
Turned Eye
High Blood Pressure
Diabetes
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?(Including Marijuana)
Type:
Amount:
How Long?

Have you ever been exposed to or infected with: 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:

Eyes

Condition Yes No
Loss Of Vision
Blurred Vision
Distorted Vision / Halos
Loss Of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy / Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing / Watering
Glare / Light Sensitivity
Eye Pain / Soreness
Chronic Eye / Lid Infection
Stys / Chalazion
Flashes / Floaters In Vision
Tired Eyes

Diabetic info:
Controlled?:
Discussed Smoking Cessation

Submit Data / Patient Signatures



Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Notice of Privacy Practices

View Notice of Privacy Practices Form

The law requires that Kara Fedders, OD, P.C. make every effort to inform you of your rights related to your personal health information. 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. under 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 UNDERSTAND 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 allowances 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:

Witness: Date:

After Completing All Forms Submit Data on Final Tab