New Patient Form

Demographics

Title	First	Last	MI	Suffix	Nickname

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?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

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.

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: