Patient Welcome Form

Demographics

How Did You Hear About Us? (Select One) Annual Postcard Local Health Fair Toys For Tots Insurance Lions Club Google Yelp! Bing Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Misc/Guardian

Preferred Language: English Spanish French Patient Declined to Specify

Ethnicity:  Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify   Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other

Billing Information

Is The Billing Address Different?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical History

Chief Vision Issues For This Visit

Secondary Vision Issues For This Visit:

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
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
ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

PATIENT MEDICAL HISTORY

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing: No Yes Unsure Not Pregnant but nursing Not Nursing but pregnant

Preferred Pharmacy: Location: Phone:

Primary Care Physician: Phone: Fax: Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years

Reason For Visit: Annual Physical Visit for a specific problem Check up    List any Vitamins you take:

Please list any Over the Counter medications:

Please list your current Prescription Medications: No Current Medications

Please list all drug allergies: No Known Drug Allergies

Smoking Status: Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other Type: None Cigaretts Chewing Tobacco Other How Long:

Alcohol: No Yes Occasionally Socially Other Type: None Beer Wine Hard Liquor Other How Long:

FAMILY MEDICAL HISTORY

Do you have a history of any of the following in your family? (Please select from the drop downs below.)
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid


PATIENT OCULAR HISTORY

Please select if you have had any of the following: Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders None

Please select your current Eye Meds: None Pataday Patanol Latacaft Elestat Alaway Lotemax Alrex Refresh Systane Blink rewetting drops Visine Genteal Xalatan Alphagan Travatan Pred Forte Vigamox Cromolyn NA 4% Other

Last Eye Doctor: Last Eye Exam: 1 year 2 years 3 years over 3 years  

Primary Vision Correction:  None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA

Type of CLs worn in past: None Disposable Conventional Colored RGP PMMA  Wear Time: 8 - 10 Hours All day Occ. Overnight Extended Disposal: 2 weeks monthly daily weekly yearly

FAMILY OCULAR HISTORY

Glaucoma: No Parents Sibling Grandparent Crossed / Lazy: No Parents Siblings Grandparent Retinal Detach: No Parents Siblings Grandparent Macular Degeneration: No Parents Siblings Grandparent Cataracts: No Parents Siblings Grandparent

DEMOGRAPHICS

Race: Patient Declined to Specify White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Ethnicity: Patient Declined to Specify Not Hispanic or Latino Hispanic or Latino Other Preferred Language: English French German Spanish Height Ft.: Inch: Weight Lbs: Please go to the next tab

Dilation/Retinal Photo

The Optomap produces a comprehensive image of your retina without the side effects of dilation. Thus, we can better prevent or reduce vision loss in our patients with a simple, quick and patient-friendly new exam. Any eye exam should always include a careful look at the retina, which is located at the back of the eye, to screen for abnormalities or disease. The sensitive tissue that makes up the retina is susceptible to a variety of diseases that can ultimately lead to partial loss of vision or even complete blindness. Early detection of any retinal abnormality is crucial. Previously, this could only be done by dilating the pupils, a procedure that many patients found uncomfortable, inconvenient and time-consuming. The Optomap, using a new technology � the Panoramic200� Retinal Imaging System, enables us to see more of your retina than observed during dilated exams without the discomfort and inconvenience associated with pupil dilation. As a result, you will not experience blurred vision or sensitivity to light following your eye exam. (Dilation results in thirty minutes of waiting and 3 or more hours of blurred vision). It is important to note however, that should any abnormalities be detected, or if we cannot obtain an acceptable image, dilation may be necessary. The Optomap exam is simple: at the push of a button, we can generate a computer image of your retina for immediate review. Experience with this technology has already led to improved disease detection and has possibly prevented vision loss and blindness in several patients.

Please go to the "Contact Lenses" Tab. If you're not getting contacts, you can proceed to the "Signature & Submittal" tab.

Contact Lenses

If you're not getting contacts, you can move to the "Submit Data" tab.

IMPORTANT INFO FOR CONTACT LENS FITTINGS AND EVALUATIONS The contact lens evaluation and fitting is a separate procedure from the standard comprehensive eye examination therefore it is charged differently. Patients that request a prescription for contact lenses will be responsible for payment of both the comprehensive examination AND the contact lens evaluation fitting. In order to get your contact lens prescription renewed, you must get a contact lens fitting every year after your previous prescription expires. The contact lens evaluation fitting includes:      - Contact lens evaluation, which includes measurements of your cornea      - Selection of contact lenses for best visual outcome      - Solution starter kit (For new wearers only)      - Diagnostic contact lenses, including proper care, insertion and removal training if necessary.      - Appropriate lens changes if needed      - Follow Up visits up to 3 months. (Extra charge after the 3 month period)      - Contact lens prescription when the proper follow-ups are taken. What if I decide to get contacts later after my standard comprehensive examination? Patients, who get a comprehensive eye exam and would like to get a contact lens evaluation fitting at a later date, must do so within a 90-day period if they wish to be charged for only the contact lens evaluation difference. Any requests for contact lens evaluation fitting after the 90-day period will require that the patient go through another full standard eye exam along with the contact lens evaluation fitting for any changes in the overall prescription.

Please go to the "Signature & Submittal" Tab.

Signature and Submittal

Signature & Submittal Page - Please Read Carefully
*PAYMENT AGREEMENT (click to view) I authorize and request my insurance company to pay directly to the eye doctor or ophthalmic group insurance benefits otherwise payable to me. I understand that my eye care insurance carrier may pay less than the actual bill for services. Therefore, I agree to be responsible for payment of the balance of all services rendered on my behalf or that of my dependents. I have the right to revoke this Authorization at any time by providing the practice with a signed written request. Until such a request is received the Authorization will be in effect for six years from the date of the most recent signed Authorization.
About Your Insurance (click to view) *NOTICE OF PRIVACY PRACTICES (click to view) You have the right to expect your personal health information to be protected as outlined in the Notice of Privacy Practices. The terms of the notice may change. If you desire, a copy of the new Notice one will be provided to you by requesting one in writing from this practice. You can request to have your consent to use your Protected Health Information revoked at any time with a signed written request to this practice. By checking this box you agree that you have read and understand this form.
*OFFICE POLICIES (click to view) By checking this box, you are providing a signature on file for Marsh Eye Center and acknowledge that you have read our office policies.

By clicking the submit button below, I acknowledge that the information that I have
inputted is correct and to the best of my knowledge. It will be updated to my medical
records at Marsh Eye Center. If I need a copy of my HIPAA rights and Marsh Eye Center office
policies, I will ask any of the staff members of Marsh Eye Center for a hard copy. If you
are a cash pay or private pay, please scroll to the bottom and submit.