Online Patient Form

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Patient Information


Title First Last MI Suffix Nickname Pronoun
Address:
Cell #:
Birthday:

Wellness

Do you have a cough?

Do you have a fever now or have you in the past 14-12 days?

Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?Do you have a cough?

Are you experiencing shortness of breath or difficulty breathing>

Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

Have you experienced recent loss of taste or smell?

Are you over the age of 60?

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Medical History

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

Referred by

Reason for Visit

Last eye exam?

Does patient wear eyeglasses?

Does patient wear contact lenses?

Right     Left     1-2 Days 3-5 Days Other N/A
Eye infection/Pain
Flashes of light
Floaters
Dry Eye
Tearing
Itchy

OCULAR HISTORY

You Mom Dad Sibling N/A
Glaucoma
ARMD
Retinal Problems
Cataracts
Lazy eye/Eye turns in



Previous eye surgeries:

OTC Eye Drops:


Ocular Medications:
Sig:
Sig:
Sig:
Sig:
Sig:
Sig:


Yes No
Glaucoma Drops
Artificial tears
Antibiotic Drops
Allergy Drops
Other


GENERAL MEDICAL HISTORY:
You Mom Dad Sibling N/A
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes
Cholesterol

Do you have Vascular issues?
None AFIB Clots < 1 Year 0-3 Years > 10 Years
Do you smoke? Yes No

Last physical examination date?

Primany care provider


Medication list:

Medication Allergies:

Review of Systems

Constitutional(Fever, weight loss, weight gain, fatigue): Yes No
Skin(Acne, rash, itching, pigmented lesions): Yes No
Neurological(Headaches, migranes, seizures): Yes No
Ear/Nose/Throat(Runny nose, ear aches, hearing changes, vertigo, sore throat): Yes No
Respiratory(Asthma, bronchitis, emphysema, COPD): Yes No
Gastrointestinal(Abdominal pain, difficulty swallowing, change in bowl habbits): Yes No
Genital/Kidney/Bladder(Kidney stones, frequent urination, impotence): Yes No
Muscles/Bones/Joints(Joint pain, arthritis, bursitis, fibromyalgia): Yes No
Blood/Lymph(Anemia, bleeding problems): Yes No
Allergic/Immunologic(Seasonal allergies, rheumatoid, AIDS, allergy shots, lupus): Yes No
Psychiatric(Depression, anxiety, insomnia): Yes No


Surgeries or Injuries:

Pregnant or Nursing?:

Social History


Race: Ethnicity: Preferred Language:

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Signatures

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I have read and agree to the above:
E-Signature: Date:

Patient Responsibility Form
1. INDIVIDUAL'S FINANCIAL RESPONSIBILITY
• I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service.
• Copayments are due at time of service
• If my plan requires a referral, I must obtain it prior to my visit.
• In the event that my health plan determines a service to be 'not payable', I will be responsible for the complete charge and agree to pay the costs of all services provided.
• If I am uninsured, I agree to pay for the medical services rendered to me at time of service.

2. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
I hereby authorize and direct payment of my medical benefits to Dr. Ralph Paternoster on my behalf for any services furnished to me by Dr. Ralph Paternoster.

3. AUTHORIZATION TO RELEASE RECORDS
I hereby authorize Dr. Ralph Paternoster to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization, or referral to other medical provider.

4. MEDICARE REQUEST FOR PAYMENT
I request payment of authorized medicare benefits to me or on my behalf for any services furnished me by Dr. Ralph Paternoster. I authorize any holder of medical or other information about me to release to medicare and its agents any information needed to determine these benefits or payments for related services.

I have read and agree to the above

E-Signature: Date: