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New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status
Emergency Contact Name Emergency Contact Phone

Referrals

Patient Referral Name
Professional Referral Name
Other
If "Other" please specify:

VISION

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address Same as Patient
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

MEDICAL

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address Same as Patient
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

PATIENT MEDICAL HISTORY

Please select any problems you may have from the drop downs below.


Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing: Recent Tetanus Shot:

Pharmacy:

Primary Care Physician: Last Visit: Reason For Visit:

List any Vitamins you take:

Please list any over the Counter medications:

Please list your current Prescription Medications: No Current Medications

Please list all drug allergies: No Known Drug Allergies
Drug Allergy Severity Reactions


FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)




Hobbies:

Smoking Status: Type: How Long:

Alcohol: Type: How Long:

Illegal Drugs: Type: How Long: STD:

PATIENT OCULAR HISTORY
Please select if you have had any of the following:
Itching
Burning, Stinging
Amblyopia
Eye Injuries
Eye Surgery
Flashes of Light
Floaters
Strabismus
Cataracts
Glaucoma
Retinal Disorders
None
Please select your current Eye Meds:
None
Pataday
Patanol
Latacaft
Elestat
Alaway
Lotemax
Alrex
Refresh
Systane
Blink

Rewetting Drops
Visine
Genteal
Xalatan
Alphagan
Travatan
Pred Forte
Vigamox
Cromolyn NA 4%
Other

Last Eye Doctor: Last Eye Exam:
 
FAMILY OCULAR HISTORY

Glaucoma:
No
Parents
Sibling
Grandparent
Crossed / Lazy:
No
Parents
Sibling
Grandparent
Retinal Detach:
No
Parents
Sibling
Grandparent
Macular Degeneration:
No
Parents
Sibling
Grandparent
Cataracts:
No
Parents
Sibling
Grandparent

Primary Vision Correction:   Planning to get new glasses?  Do you have backup glasses?

Type of CLs worn in past:  Wear Time: Cleaner: Disposal:

Preferred Language:  Ethnicity:   Race: 
 

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
 ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

Optomap Exam

Heritage Family Eye Care offers a state-of-the-art digital scanning technology that allows us to view the inside of your eye without the use of dilation drops. The OPTOMAP allows us to evaluate your retina for problems such as macular degeneration, retinal holes, retinal detachments, hypertension, and diabetic retinopathy. The OPTOMAP is safe for kids and adults and allows you the opportunity to see the inside of your eye just as the doctor sees it.

Dilated Exam vs. Optomap Exam
  1. Blurred near vision for 4-6 hours
  2. Light sensitivity for 4-6 hours
  3. Longer office visit waiting for drops
  4. No permanent record of retina
  5. Only the doctor can see the retina that can be reviewed and compared each year
  1. NO blurred vision
  2. NO light sensitivity
  3. Map takes less than 2 to take effect minutes to process
  4. Permanent digital image
  5. You can see the retina

Early Detection is Crucial!

Our doctors strongly recommend that ALL patients have a thorough examination of their retina every year. **Without the OPTOMAP or a dilated examination, the doctor cannot fully assess the health of your eye.

There is an additional fee of $35.00 for the OPTOMAP. This procedure is not covered by insurance. *Dilation may still be required in rare instances.

I elect to have a digital image of my retinas today ($35.00)
I prefer a dilated exam of my retinas today (no additional fee) and I have been informed of the side effects listed above
I will decline both options today and I understand that the doctor cannot fully assess the health of my eyes without this procedure.

Receipt of Notice of Privacy Policies

Click Here to View Our Notice of Privacy Practices
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In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office.

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office.

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and to perform healthcare operations. You also signify that you have received a copy of our Notice of Privacy Practices.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Heritage Family EyeCare.

Your signature below signifies your acceptance of these policies. Do not sign if you do not consent.


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