Crystal PM Patient Forms

Demographics

General Information

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
Email
Birthdate		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:

Medical History

PERSONAL HISTORY The top line questions are required by Federal Law
Race Preferred Language Height Ft. In. Weight (lbs.)

Referred By Date of Last Eye Exam Last Eye Dr.

Currently Wear Glasses? No Yes Yes, Part-Time
Currently Wear Contacts? No Yes Yes, Part-Time

Hobbies / Special Visual Needs: Interested in Refractive Surgery? Computer Use (Hours/day)?

REASONS for Today's Visit

MEDICAL Complaint #1	VISION Complaint #1
MEDICAL Complaint #2	VISION Complaint #2
MEDICAL Complaint #3

PERSONAL MEDICAL HISTORY - REVIEW OF SYSTEMS

Allergic/Immunologic No Endocrine No Hematologic/Lymph No

Cardiovascular No Eyes No Integumentary / Skin No

Constitutional No Gastrointestinal No Musculoskeletal No

Psychiatric No Reproductive
No Respiratory No

Ears, Nose, Throat: No Genitourinary No Neurological No

Cancer No

Personal Ocular History - additional:
Current Medications - Please list below or No Current Medications

Medication - Drug Allergy - Please list below or No Known Drug Allergies (NKDA)

Your Eye Problems

Eyes Red / Burning	Poor Night Vision	Itchy Eyes	Stye	Tired Eyes
Dry / Watery Eyes	Blurred Near Vision	Blurred Far Vision	Floaters	Headaches
Flashes Of Light	Eye Pressure	Discharge In Eyes	Other(s)

FAMILY MEDICAL HISTORY Family Eye History:
Family Med History:

SOCIAL HISTORY Smoking Status? Drink Alcohol? Use Illegal Drugs?
Please list any additional personal history:

Forms

PLEASE REVIEW THE FOLLOWING OFFICE FORMS You agree that by Signing and entering initials, you are providing your consent to the use of the Electronic Document and such election constitutes your electronic signature and consent, and you agree to be bound by the terms and conditions in such Electronic Documents to the same extent as you had signed a paper document.

Insurance Billing Summary

**View Insurance Billing Summary**
Vision Plan
(VSP, Versant, Davis, Superior, etc.)
A vision discount plan pays for determining a prescription for glasses/contacts and purchase of eyewear and lenses. If you have complaints, symptoms, or history of medical eye conditions, a vision plan will not cover the fee for those medical services. Initials

Medical Insurance
(Blue Cross, United Healthcare, Aetna, Medicare, etc.) This covers medical eye problems. Conditions such as diabetes, infections, allergies, dry eyes, cataracts, retina problems or glaucoma mandate that doctors are required by law to file the medical insurance (not with vision plans). Initials

I authorize any holder of medical information about me to release to Centers for Medicare/Medicaid Services or my insurance companies any information needed to determine these benefits or the benefits payable for related services. I also authorize payment of insurance benefits, otherwise payable to me, directly to Master Eye Associates (TAX ID 58-2413634) for services they furnish.
Signature: Date:

Acknowledgment Of Receipt Of Notice Of Privacy Practices

**View Patient Privacy Policy**

I acknowledge that I reviewed the Notice of Privacy Practices and that a copy has been made available to me upon request.
Signature: Date:

View Financial Policy & Agreement, Pre-authorized Payment Agreement, Insurance Authorization

**View Financial Policy & Agreement, Pre-authorized Payment Agreement, Insurance Authorization**

I authorize Master Eye Associates to keep my signature on file and to charge my MasterCard or VISA the balance of charges not paid by my insurance (not to exceed $500) for all professional services during the next 12 months. I assign my insurance benefits to Master Eye Associates. I understand this authorization is valid for one year unless I cancel by written notice to Master Eye Associates. I understand and agree to the Financial Policy & Agreement.
Signature: Date:

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Allergic/Immunologic	No	Endocrine	No	Hematologic/Lymph	No
Cardiovascular	No	Eyes	No	Integumentary / Skin	No
Constitutional	No	Gastrointestinal	No	Musculoskeletal	No
Psychiatric	No	Reproductive	No	Respiratory	No
Ears, Nose, Throat:	No	Genitourinary	No	Neurological	No
Cancer	No