4092 Danada Vision Center LLC

Name*

First Last

Gender:*

Date of birth:*

Age:*

Social Security Number:*

Employer:

Marital Status:*

Address*

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

Work Phone:

Home Phone:*

Vision Insurance:*

Subscriber Name:*

Subscriber ID:*

Subscriber DOB:*

Secondary Vision Insurance:

Subscriber ID:

Medical Insurance:*

Subscriber Name:*

Subscriber DOB*

Subscriber ID:*

Email

Reason for Visit - Check all that apply*

Routine Exam
Contacts
Eye Infection/ Injury
Eye Lash Treatment
Glasses
Sunglasses
Dry Eye Treatment
Lasik Consult

Las Eye Exam:*

1 Year
2 Years
3+ Years

Have you had eye surgery? If yes please explain:*

Do you wear glasses?*

EYE HISTORY - Do you Have or have you ever had a problem in the following areas:

FAMILY HISTORY- Ocular:

Macular Degeneration
Blindness/ Vision Impairment
Cataracts
Glaucoma

Please list relationship to person(s) with listed conditions:

FAMILY HISTORY- Medical:

Cancer
Diabetes Type 1
Diabetes Type 2
High Blood Pressure
Thyroid Disease
Heart Disease

Please list relationship to person(s) with listed conditions:

Do you have or have you ever had any history of - CONSTITUTIONAL:

Cancer
Developmental Disability
Fever
Weight loss/gain

EAR, NOSE, MOUTH AND THROAT:

Hearing Loss
Dry Mouth
Sinus Congestion
Post Nasal Drip
Chronic Cough

NEUROLOGICAL:

Multiple Sclerosis
Epilepsy
Tumor
Stroke
Headaches/ Migraines
Autism

PSYCHIATRIC:

Anxiety/ Depression
Bipolar/ Schizophrenia
Attention Deficit

CARDIOVASCULAR/ VASCULAR:

High Blood Pressure
High Cholesterol
Vascular Disease
Congestive Heart Failure
Heart Disease

RESPIRATORY:

Smoke/ Tobacco Products
Asthma
Chronic Bronchitis
Emphysema
Snoring/ Sleep Apnea

GASTROINTESTINAL:

Crohns Disease
Colitis
Ulcer
Acid Reflux
Celiac Disease

GENITOURINARY:

Kidney/ Bladder Problems
STD

If yes to STD question please list:

Bones/ Joints/ Muscles

Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Muscle/ Joint Pain
Rheumatoid Arthritis

INTEGUMENTARY:

Eczema:
Rosacea
Psoriasis
Shingles/ Herpes

ENDO:

Diabetes Type 1
Diabetes Type 2
Thyroid Dysfunction
Hormonal Dysfunction

HEM/ LYMPH:

Anemia
Ulcer
Hypercholesteremia

ALLERGY:

Seasonal/ Environmental
Sjrogens Syndrome
Other:

If other please list:

Please note any additional health history not listed:

HIPAA ACKNOWLEDGMENT:*

Your signature acknowledges that you have read a copy or been given the opportunity to read Danada Vision Center Notice of Privacy Practices. Federal regulations (Health Insurance Portability and Accountability Act - HIPAA) Require we ask for your signature of receipt.

Name*

First Last

CONSENT FOR TREATMENT AND FINANCIAL POLICY:*

By signing this form I consent to treatment for myself and/ or on behalf of the minor for which this information pertains. I giver permission for the Doctor(s) to examine, diagnose and initiate treatment as deemed appropriate.I further, attest that I am the parent or legal guardian of the Minor and have the authority to authorize care and treatment. I agree to be responsible for all services rendered on my behalf or my dependents. I understand I am responsible for any and all fees my insurance does not cover. I understand that payment is due at the time of service unless other arrangements are made. I have read and agreed to Danada Vision Center's Financial Policy. Please understand, since an order for glasses is a custom prescription designed for each individual patient, once it is in progress, we will be unable to cancel the order.

Name*

First Last

Date*

Relationship to patient: