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:

Chief Complaint


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Chief Complaint
Reason for Visit:
Secondary Complaints:

Review of Ocular System
Ocular History:
When was your last Eye Exam:     Have you ever had EYE surgery?

Which EYE?     When?     What type of EYE surgery?

Family Ocular History
Glaucoma: Cataracts: Macular Degeneration:
Retinal Detachment: Crossed or Lazy eye:

Other EYE problems in the family not listed:

Personal Notes:


Medical History


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Patient Medical History List your PAST MAJOR illnesses and injuries:
List your PAST surgeries and hospitalizations:

Current Medications:         No current meds Drug Allergies:         No known drug allergies

Other Allergies: Over The Counter Meds: Vitamins:

Smoking Status: Type: How Long:

Last physical exam

Family Medical History


Review of Systems


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Review of Systems
ENDOCRINE: Diabetes, Thyroid, Ovaries, Testes, etc.
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus, etc.
INTEGUMENTARY (Skin and Breasts): eczema, growths, rashes, acne, breast disorder, etc.
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease, etc.
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat, etc.
CONSTITUTIONAL SYMPTOMS: Fever, weight loss, weight gain, fatigue, etc.
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux, etc.
GENITOURINARY: Kidneys, Bladder, Prostate, Uterus, etc.
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems, etc.
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury, etc.
NEUROLOGICAL: Headaches, Migraines, Seizures, Stroke, etc.
PSYCHIATRIC: Depression, Anxiety, Bipolar, Compulsive, Insomnia, etc.
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD, etc.


COVID

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition Yes No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis, Or Have You Been Asked To Quarantine?


Submit Data / HIPAA ACKNOWLEDGEMENT



HIPAA ACKNOWLEDGEMENT FORM

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operation. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

The patient understands that:

    * Protected health information may be disclosed or used for treatment, payment or health care operations
    * The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
    * The Practice reserves the right to change the Notice of Privacy Policies
    * The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
    * The patient may revoke this Consent in writing at any time and all future disclosures will then cease
    * The Practice may condition treatment upon the execution of this Consent

Patient Name:
Signature:
Relationship To Patient:
Date: