EmailMe Form - Patient Infomation Form

Last Name: *

First Name: *

Nickname:

If above is a child, name of parent(s):

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Telephone Cell: *

### - ### - ####

Home:

### - ### - ####

Work:

### - ### - ####

Email *

Date Of Birth:

Social Security #:

XXX-XX-XXXX
(For use in patient identification with health insurance coverage; if submitted in person at time of appointment, we cannot verify insurance coverage or eligability.)

Employer:

Occupation:

Spouse / Partner Name:

Spouse / Partner Occupation:

Name and Age of Children:

For School Age Patients

School:

For School Age Patients

Grade:

For School Age Patients

How did you find out about our office?

Friend

Relative

Health Care Provider Name:

Co-worker Name:

Advertising

Television, Radio, Yellow Pages

Insurance Provider Listing

Internet

Other

Insurance Information

Please complete the following insurance items, and please bring all insurance cards

Medical Insurance

Vision Insurance

Do you have a flex spending account?

Yes

No

Responsible individual for payment:

Self

Other

Vision Information

Check any of the boxes that apply to your lifestyle

Date Of Last Examination:

MM / DD / YYYY

Doctor or Clinic Name:

At the time of your examination, do you PLAN to:

Purchase new eyeglasses?

Purchase a new supply of contact lenses?

Regarding your OUTDOOR lifestyle, do you:

Do a lot of night driving?

Spend time outdoors in direct UV radiation?

Read outdoors?

Have need to protect your eyes while working?

Have light sensitivity?

Regarding your INDOOR life, do you:

Work on a computer?

Have more than one pair of prescription glasses for multiple tasks?

If you wear Contact Lenses:

I have an interest in trying the latest contact lens technology

I am not satisfied with my vision and/or comfort.

I wear sunglasses with my contact lenses.

I am interested in multifocal contact lenses.

I have interest in color-enhanced lenses.

Please use this space to make any additional comments or to raise concerns regarding your vision, as well as the main reason for your visit:

Check any eye conditions, diseases, or procedures that you currently have, or have experienced:

Doctor or Clinic Name:

Date Of Last Physical Examination:

MM / DD / YYYY

For Women

Due Date If Pregnant:

MM / DD / YYYY

Please check if you are a nursing mother.

Please check if you are currently taking birth control.

Please check if you are on hormone replacement therapy

Personal Health Information

Please check the box for any disorder that you have, and list the medication(s) for the condition:

General Health

Other Disorder(s)

Cardiovascular

Other Disorder(s)

Endocrine

Other Disorder(s)

Neurological

Other Disorder(s)

Integumentary

Other Disorder(s)

Ears/Nose/Mouth/Throat

Other Disorder(s)

Allergic/Immunologic

No Disorder

Drug Allergies

Environmental Allergies

Rheumatoid Arthritis

Lupus

Latex Allergy

Medication(s)

Other Disorder(s)

Respiratory

No Disorder

Cigarette Smoker

Cigarettes per day

Other Disorder(s)

Musculoskeletal

Other Disorder(s)

Gastrointestinal

Other Disorder(s)

Genitourinary

Other Disorder(s)

Hematologic/Lymphatic

Other Disorder(s)

Psychiatric

No Disorder

Depression

Medication(s)

Other Disorder(s)

Please list anything else we should know about your health:

Family Information

Indicate immediate family members with any of the following eye or health disorders:

Glaucoma:

Who?

High Blood Pressure:

Who?

Macular Degeneration:

Who?

Diabetes:

Who?

Cataract:

Who?

Cancer:

Who?

Other eye disorders:

Who?

Other health disorders:

Who?

Appointment Checklist

Be sure to bring the following to your appointment

* Glasses
* Contact Lenses
* Contact Lens Boxes or Prescription
* Insurance Information

Accounting Information

Personal Check or Cash

Credit Card - Visa/Mastercard/AmericanExpress/Discover

Care Credit

Preferred method of payment for fees for materials and services not covered by insurance:

Policies for payment:

1. Fees for materials such as glasses or contacts are due at the time of order.
2. Family Eye Care has financing or payment plans available with Care Credit.
3. Any fees for examinations or materials that are not covered by insurance are due at the time services are rendered.
4. I authorize payment of insurance benefits directly to Family Eye Care, P.C.

By marking this checkbox I understand my obligation for payment as described above.

By submitting this form you acknowledge the following statement:

I understand the above information is necessary to provide me with eye and vision care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge. With my approval, I authorize the Doctor to perform diagnostic procedures and treatments as may be necessary for proper eye and vision care. I understand my obligation for payment as described above.