Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at (435) 656-2003. We can always change the data in the office if you are unsure about what to enter in any of the fields.
Please CLICK HERE to print the form. Please complete all applicable fields and
submit to our staff at the time of your appointment.

Patient Information

*required (first and last name and either a home OR cell phone)

TitleFirst*Last*MISuffixNickname
Address  
City St  Zip
Hm Phone*
Cell Phone*
Wk Phone
Other Phone
Email
Preferred Contact By
DOB (mm/dd/yyyy)  
Sex Female Male
Marital Status
Employment Status Employed FT Student PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race
Ethnicity
Preferred Language

Who may we thank for referring you to our office?  

Billing Information

Is The Billing Address the Same?

TitleFirstLastMISuffix
Address
City St  Zip
Hm Phone  
Wk Phone

Vision Insurance

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 Insurance

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:

General Medical History

Primary physician's name and phone  
When was your last physical exam?

Check the box for any conditions that apply:

You Mom Dad Sib Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes
If YOU are diabetic, when were you diagnosed?    Last A1C level? 
Are you Pregnant or Nursing?  

 Name of MedicationFrequencyRoute of AdministrationDuration
1.
2.
3.
4.
5.
Please list any additional medications and their dosing regimens:
List ALL major injuries or surgeries you have had and approx dates:
List any other medical conditions you have had, including non-drug allergies:
List any vitamins or supplements you currently take:
List any drug allergies you have:
Smoking Status
Alcohol Use
Do you live alone?  

Review of Systems

Please list any problems you are currently having anywhere, from head to toe:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)
Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)
Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)
Respiratory (e.g., chronic cough, shortness of breath, wheezing)
Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)
Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)
Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)
Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)
Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)
Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)
Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)
Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Ocular History

Who was your previous eye doctor?  
When was your last eye exam?

Check the box for any conditions that apply:

You Mom Dad Sib Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn
List any major eye injuries, infections or surgeries and approx dates:
List any other significant eye problems you have had:
List all Rx and over-the-counter eye medications you currently use:
List any vision complaints you are currently having such as:
  • blurred vision, headaches, eyestrain, double vision, or losing your place when reading
  • itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
  • seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs
How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes? 
How many hours/day do you typically spend reading books, magazines, etc?
What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glassess?
Are you interested in contacts?
Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?



RECOMMENDED DIAGNOSTIC TESTS

We strongly recommend as your eye care professionals, that all patients receive the following tests. These tests are included as part of our comprehensive eye exam. (Please note: Our basic eye exam does not include these tests.)
  • Visual Field Screening - A new and highly sophisticated instrument enables us to check for loss of sight centrally and peripherally. This assists us in the detection of glaucoma and other eye diseases. If further testing is required that could incur additional costs this will be discussed and permission received prior to performing those tests.
  • Dilation - This test allows Dr. Fife to thoroughly evaluate the inside health of the eyes.

SPECTACLE REMAKE POLICY

We will start your custom spectacle order immediately. For this reason, cancellations on spectacles are not permitted. All glasses are custom crafted for each patient with their unique prescription. Also, all spectacle lenses are custom cut to fit the frame each patient has selected. Therefore, patients may not switch frames after their lenses have been cut. Our lab charges us to create your spectacles. Once they begin the process, they will not refund your money to us. For these reasons, cash refunds are not possible. At the doctor's discretion, patients who are not satisfied with the vision in their new glasses will have their prescription adjusted at no cost, within 30 days of the original purchase date. Cash refunds are not available on any lenses including progressive lenses. However, any patient who fails to adapt to their new progressives will have their prescription remade one time into a lens of their choice at no additional charge.

*We require payment in full on all eyeglass and contact lens orders.


Financial Responsibilities:

You (or your legal guardian) are responsible for the payment of your account including payment of co-pays, coinsurance, deductible, all other procedures or treatment not covered by your/his/her insurance plan and all direct or indirect fees incurred in collecting any outstanding balance.

While we will assist in filing for insurance, we cannot guarantee coverage. As the insured, you are responsible for knowing your insurance benefits and requirements for coverage and ensuring that any necessary referrals or authorizations are obtained before receiving services. In the event of a dispute or rejection of a claim you are responsible for payment.
We may file some types of insurance for you as a courtesy, however; you are responsible for staying in contact with the insurance company to assure that they pay in a timely manner. We may require payment for your services in full if your insurance company has not paid the benefits to us within 90 days of submission. Any insurance benefits that are later received for those services will be refunded to you. Payment is due at the time of the service. We accept cash, check, debit, Care Credit, Visa and MasterCard.
Bring your insurance card and picture ID to each visit.
Notify our office of any changes in your address, phone or insurance.
There will be a $25.00 fee plus our banks fee for a returned check.
A finance charge of 1.5% per month (18% per year) will be charged for any balance over 30 days past due.
Canceled Appointments:
While we understand that there may be times when you miss an appointment due to emergencies or obligations, we ask that you give us 24 hour notice on all canceled appointments. If you repeatedly miss appointments without any notification you will only be seen on a walk-in, space available basis or will be required to pay for your appointment in advance and payment will be forfeited if you do not show. Insurance does not cover missed appointments.

Records Release:

We will provide a report of your most recent exam results and current spectacle and contact lens prescriptions at no charge. If you request copies of your full medical records, there will be a charge of $.25 per page and we may impose a minimum handling fee (including copies) of $10 plus the cost of any delivery method that you choose (or the fee allowed by the State of Utah at the time of the request). All charges must be paid before the records will be released.

Acknowledgements:

I have read, understand and agree to the policies outlined above.

  • I consent to the performing of optometric procedures agreed to be necessary or advisable.
  • I authorize the release of any information contained in my records for the purpose of my treatment, billing and processing of insurance claims and I authorize payment of benefits to Paradise Canyon Eye Care and/or Joseph Fife, OD.
  • The duration of this document is indefinite and continues until revoked in writing.

Notice of Privacy Practices:

I acknowledge that a copy of the Paradise Canyon Eye Care Notice of Privacy Practices has been made available to me (which is also found on our website).

Please check, sign, and date that you have read, understand, and agree:

Check:

Signature:

Date:


You're Done! Please hit the Submit button below.