Somerset Eye Care

Online Forms

Please verify that the information below is correct, fill in any blanks, and make any necessary changes.

P.S.:Don't forget to click "Submit Data" on the bottom of this page when you're done!
TitleFirstLastMISuffixNickname
Address:
City: State
Zip Code:

Home Phone: Work Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student Retired Unemployed
Marital Status Employer/School Name
Height*:ft in
Weight*:lbs Preferred Language
Race*
Ethnicity*

*We need this information as a part of the American Recovery and Reinvestment Act (ARRA) of 2009.

Please tell us about your eyes:

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Only answer the following if you currently wear glasses:

I currently wear glasses: Full-time Part-time (If part-time, how often/when? )

Only answer the following if you currently wear contacts:

I currently wear contacts: Full-time Part-time (If part-time, how often/when? )

Current Brand: My contacts are: Soft Rigid Gas Permeable

Are you currently comfortable in your contacts?Yes No

When do you typically switch into a new pair of contacts?

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Please list any eye drops you currently use (OTC and Rx): How often do you use them?:

Do you have a history of/ or currently suffer from:

BlindnessYes    No
Eye Turn Yes    No
Lazy EyeYes    No
KeratoconusYes    No
GlaucomaYes    No
CataractsYes    No
Macular DegenerationYes    No
Retinal DetachmentYes    No
HeadachesYes    No
Blurred Vision Yes    No
Double VisionYes    No
Tired/Painful eyesYes    No

Halos Around LightsYes    No
Light SensitivityYes    No
Frequent StyesYes    No
Redness/IrritationYes     No
ItchingYes    No
BurningYes    No
TearingYes    No
DrynessYes    No
Sandy/GrittyYes    No
Flashing LightsYes    No
FloatersYes    No

Have you had any eye injuries? No
If yes, please detail:

How about eye surgeries?No
If yes, please detail:

Tell us about your general health:

Primary Care Physician's Name:When was your last physical?
Pharmacy Name:Pharmacy Phone Number:

List all medications you are currently taking (including any OTC/vitamins):
I currently do NOT take any medications


List any medications you are allergic to:
I currently do NOT have any medical allergies


Are you pregnant or nursing? NoYes    If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas?
YES   NO
  Diabetes   If yes, how many years have you been a diabetic?
  High blood pressure
  High Cholesterol
  Heart Disease
  Kidney Disease
  Thyroid problems
  Gastrointestinal
  Neurological (Brain)
  Migraines
  Stroke
  Skin Condition
  Arthritis
  Asthma/Lung/Respiratory Problems
  Cancer
  Anemia
  Multiple Sclerosis
  Allergies/Hay fever
  HIV
  Hepatitis
  Emphysema
  Herpes/Shingles
How often do you smoke/use tobacco products?

How often do you consume alcohol? (Be honest!)

Now, tell us about your family:

My Family history is unknown/I was adopted

Any history of the following in any family members? (If Yes, please mention relationship to patient in text box.)

Poor Vision No Yes
Cancer No Yes
Blindness No Yes
Diabetes No Yes
Eye Turn No Yes
High Blood Pressure No Yes
Lazy Eye No Yes
Stroke No Yes
Glaucoma No Yes
Thyroid Disease No Yes
Cataracts No Yes
Retinal Detachment/Disease No Yes
Macular Degeneration No Yes

How did you hear about Somerset Eye Care?

If applicable, please enter the name of the person or detail how you were referred to our office:

RETINA PHOTOGRAPHS

Our doctors strongly recommend digital retinal photography as part of the yearly eye exam for all patients. These eye wellness photographs are a permanent record in your medical file that allow the doctors to better diagnose and document many eye conditions year after year. Most insurances do not cover the fee for the procedure ($39). If you would like additional information before having the photographs taken, please notify the Technician or Doctor.

Additional Information

Most insurance policies pay only a portion of your total charges. If you have questions about your coverage, please contact your representative. It is your responsibility to verify coverage for the services provided. We can not guarantee the accuracy of benefit information given to us by insurance companies.

I understand that the financial responsibility for my account is mine, and not the insurance company's. I understand that any balances not covered by insurance are my sole responsibility and that if my account is sent to a collection agency due to unpaid balances, then a $30 collection fee will be added to my account.

I authorize the release of any medical or other information necessary to process insurance claims. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the physician for services rendered. I have read and agree to the Notice of Privacy Practices for Somerset Eye Care.

I have read and agree to the above statement.

Initials: