Central Oregon Eyecare New Patient Forms
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Demographics

Patient Registration Form
Title First Last MI Suffix Preferred Name
Address:
City: State: ZipCode:
Cell #: Work #:
Home #: Other #:
Email: Emergency Contact Info:
Preferred Contact Method:
DOB:
mm/dd/yyyy
Sex:
Marital Status:
Employment Status:

Employer/School Name:
Occupation:
Billing Information
Title First Last MI Suffix
Address:
City: State: ZipCode:
Home Phone:
Work Phone:

Insurance Information

Primary Vision Insurance Information
Insurance Company Name:
Insurance/Subscriber ID#:
Insurance Policy Group#:
Primary Subscriber Information
Name:
Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Date of Birth: mm/dd/yyyy
Employer/School:
Secondary Vision Insurance Information
Insurance Company Name:
Insurance/Subscriber ID#:
Insurance Policy Group #:
Primary Subscriber Information
Name:
Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Date of Birth: mm/dd/yyyy
Employer/School:
PRIMARY Medical Insurance Information
Insurance Company Name:
Insurance/Subscriber ID#:
Insurance Policy Group #:
Primary Subscriber Information
Name:
Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Date of Birth: mm/dd/yyyy
Employer/School:
SECONDARY Medical Insurance Information
Insurance Company Name:
Insurance/Subscriber ID#:
Insurance Policy Group #:
Primary Subscriber Information
Name:
Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Date of Birth: mm/dd/yyyy
Employer/School:
TERTIARY Medical Insurance Information
Insurance Company Name:
Insurance/Subscriber ID#:
Insurance Policy Group #:
Primary Subscriber Information
Name:
Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Date of Birth: mm/dd/yyyy
Employer/School:

Medical History

Eye Health History
When was your last eye exam?
By Whom?
Who is your Primary Care Physician?
Last Visit with PCP:
Reason for visit:
Who were you referred by?

Please list any MEDICATION ALLERGIES (including over the counter or eye drops):
Please list all EYE MEDICATIONS you are currently using including over the counter non-prescription eye medications and drops:
Please list all OTHER MEDICATIONS you are currently taking and the condition for which you are taking them:
(including over the counter non-prescription supplements and medicines)
Please list any Injuries, Surgeries, or Hospitalizations you have had:

The following questions are Federally Mandated for all health professionals. Your information will be kept completely annonymous.
Height: ft in Weight: lbs
Do you smoke? What type? How long have you smoked?

Race: Ethnicity:
Preferred Language:

SOCIAL HISTORY
What is your current OCCUPATION?
What are your HOBBIES?
Do you use ALCOHOL? What type? How long?
Do you use ILLEGAL DRUGS? What type? How long?
Do you have any STDs?

VISION HISTORY
What is your primary vision correction?
If you wear contact lenses, what type of contact lenses are you currently wearing?
How often do you change your contacts?
What type of cleaner do you use?
Do you have BACK-UP GLASSES?
Are you planning to get: New Glasses?
Contact Lenses?
LASIK?
Do you suffer from any of the following EYE CONDITIONS or SYMPTOMS? Please check all that apply:
Allergies Macular Degeneration Cataracts Chronic Eye/Lid Infections
Diplopia/Double Vision Distortion or Halos Eye Strain Eye Turn/Lazy Eye
Flashes or Floaters Glare or Light Sensitivity Glaucoma Loss of Vision
Mucous Discharge Redness Retina Problems Eye Surgeries

PERSONAL HEALTH HISTORY
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
ENDORCRINE:
Thyroid, Diabetes
BLOOD/LYMPH:
Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC:
Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL:
Diarrhea, Constipation, Ulcer, Reflux
Please list any other medical conditions ("Other") that you may have or feel we should be aware of:
FAMILY OCULAR/MEDICAL HISTORY
Does anyone in your family have the following?
Glaucoma: Cataracts: Diabetes:
Macular Degeneration: Retinal Detachment: High Blood Pressure:
Crossed / Lazy:
Any other MAJOR MEDICAL Conditions that we should be aware of?

DRY EYE HISTORY Which of the following environmental factors for Dry Eye apply to you?
Do you suffer from any of Systemic Conditions?
Do you take any Systemic Medications?
Do you take any Ocular Medications?
Do you use any Artificial Tears?
Do you have any signs of Dry Eye Syndrome?
What happens when you wear Contact Lenses?

Have you ever experienced the following: Are you limited in performing the following: Are you uncomfortable in the following:
Sensitivity to light? Reading? Windy conditions?
Gritty feeling? Driving at night? Low humidty?
Painful or sore? Computer use? Air conditioning?
Blurred vision? Watching TV?
Poor vision

Submit Information

Financial Policy & Review

Thank you for choosing Central Oregon Eyecare for your eye health needs. At Central Oregon Eyecare, we do our best to exceed your expectations in a friendly, efficient manner. We appreciate your trust in us.

As a courtesy, we attempt to verify your insurance benefits from your carrier, and bill your insurance company accordingly. Your co-pay, any deductibles not met, and non-covered services are expected at the time of service. Any prices quoted are estimates based on the information we received from your insurance.

In the event that your insurance denies coverage or applies any billed amounts to your deductible, the remaining charges will become your responsibility. By cooperating with this agreement, we will be able to continue offering service that meets the needs of all who trust us with their care.

If your insurance has not paid your claim within 60 days of filing, we will ask your assistance in contacting your insurance company. Insurance balances not paid by your carrier within 90 days will become your responsibility. Any amounts not paid by you after 120 days will be assigned to Cascade Credit Consulting with a 50% collection fee.

We understand that occasionally you need to change an appointment with us. As a courtesy, we ask that you give us at least 24 hours notice if you need to cancel, or reschedule an appointment. Appointments cancelled, rescheduled or missed without 24 hours notice will be subject to a $35 missed appointment fee. Additionally, we do not accept cancellations via text, email, or by voicemail.

Thank you for taking the time to complete your online Vision and Eye Health History form. You may click on the tabs above to review the information you have provided. Click on the button below to submit your information.