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


CHIEF COMPLAINT


SECONDARY COMPLAINTS:


FAMILY OCULAR HISTORY
Crossed / Lazy:


Retinal Detach:


Macular Degen:


Cataracts:


Glaucoma:


REVIEW OF SYSTEMS:
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


MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury


SKIN: growths, rashes, acne


NEUROLOGICAL: Headaches, migraines, seizures


PSYCHIATRIC: Depression, Anxiety, Insomnia


ENDORCRINE: Thyroid, Diabetes


BLOOD/LYMPH: Anemia, cholesterol, bleeding problems


ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus


FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other













HEIGHT: FOOT INCHES

WEIGHT: POUNDS

TOBACCO:

ALCOHOL:

PREFERRED LANGUAGE:

ETHNICITY:

RACE:

Notice Of Privacy Practices



ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I certify that I have been made aware of Dr. Son and Associates' Notice of Privacy Practices and that I have a right to receive a copy upon request. This Notice describes the type of uses and disclosures of my protected health information that might occur during my treatment, to facilitate the payment of my bills or in the performance of Dr. Son and Associates' health care operations. The Notice also describes my rights and Dr. Son and Associates' duties with respect to my protected health information. I understand that copies of the Notice of Privacy Practices are available at the front desk. I may request that a copy be mailed to me by calling 703-748-1366

Dr. Son and Associates reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the above number and requesting a revised copy be mailed to me, by asking for one at the time of my next appointment.

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
NAME OF PATIENT OR PERSONAL REPRESENTATIVE
DATE
DESCRIPTION OF PERSONAL REPRESENTATIVE'S AUTHORITY


Retinal Photos


RETINAL PHOTOGRAPHY

A new, highly sophisticated, digital camera now enables us to provide a more thorough retinal analysis of your eyes. Photo-documentation is painless and in most cases can substitute a dilated examination of your retina. It can also be an excellent reference point from which future comparison can be made.

Retinal photography can assist us in the early detection of optic nerve disease, pre-cancerous lesions, macular degeneration, hypertensive retinopathy, diabetic retinopathy, any many other retinal disorders such as retinal detachment, holes, and thinning.

We strongly recommend that all of our patients receive this test. It is especially important for all people over the age of 35, as well as those patients who have a history of high blood pressure, diabetes, retinal problems, headaches, or a strong prescription for glasses.

There is an additional charge of $39 for the retinal photography. Please indicate if you would like to opt for this evaluation.






Please note: While this test is "optional" for some people as it represents preventative health care, for others, retinal photo-documentation is "required" because of certain retinal conditions that may be present or need to be "ruled out." In this latter case, you may be able to submit your bill for the retinal photography to your major medical insurance company for possible reimbursement.

Submit Data

After Completing All Forms Submit Data on Final Tab