[5299] Oxford Family Vision Care

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Oxford

Jeffrey W. Collins, O.D., M.S

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127 Lynn Avenue

Oxford, Ohio 45056

Telephone (513) 523-6339

Fax (513) 523-6330

email: mailbox@OxfordFamilyVisionCare.com

www.OxfordFamilyVisionCare.com

Patient information

Thank you for choosing our practice for your eye care needs. Please complete this form. If you have questions or concerns, do not hesitate to ask for assistance. We will be happy to help.

Date(Required)

MM slash DD slash YYYY

Untitled

Miss

Ms.

Mrs.

Mr.

Dr.

Name(Required)

First Middle Last

SS#(Required)

Driver's Lic #

Home (Permanent) Address(Required)

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

Birthdate(Required)

MM slash DD slash YYYY

Age(Required)

Sex(Required)

Home phone #(Required)

Work phone #

Cell phone #

Email Address

Your or your parent's employer

Occupation

Business Address

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

If you are a student, name of school/college

Grade

Address

City State / Province / Region ZIP / Postal Code Country

Whom may we thank for referring you to our office?

Name of Relative

Address

Phone #

Responsible party

Name of person responsible for this account?

Relationship to patient

Driver's Lic #

SS#

Phone #

Address

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

Name of employer

Work phone #

Hidden

Insurance Information

Name of insured

Birthdate

MM slash DD slash YYYY

Social Security #

Relationship to patient

Name of employer

Insurance co.

DO YOU HAVE ADDITIONAL INSURANCE?(Required)

Yes

IF YES, PLEASE COMPLETE THE FOLLOWING:

Name of insured(Required)

Birthdate

MM slash DD slash YYYY

Relationship to patient

Social Security #

Insurance Co.(Required)

Name of employer

Authorization

Please choose payment choice(Required)

Cash

Check

Visa/ Master Card

Discover

Vision Care Insurance

Other

(Please specify)(Required)

Signature of Patient/Guardian(Required)

Date(Required)

MM slash DD slash YYYY

Full payment due upon completion of services.

For your convenience, we accept VISA, MasterCard, and Discover.

Accounts 30 days past due subject to a rebilling fee of 2.0% (min. $2.50) per month.

As a courtesy, we will bill your vision care insurance for you. However, we are not responsible for collecting your claim or negotiating settlement on a disputed claim. You are responsible for payment of your account within the limits of our credit policy.

I authorize the optometrist to release any information acquired in the course of examination or treatment for insurance purposes. I acknowledge that I am responsible for non-covered services. I authorize and request my insurance company to pay directly to the optometrist insurance benefits otherwise payable to me. I understand that my eyecare insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Thank you for choosing our practice for your eye care need. To update our records please fill out the information below. If you have any questions or concerns please free to ask for assistance, we are happy to help.

Name

First Last

Family History: Does anyone in your immediate family (blood relative) have a history of the following? If YES, Who?

Diabetes

Diabetes - If yes who?(Required)

Glaucoma

Glaucoma - If yes who?(Required)

Blindness

Blindness - If yes who?(Required)

Cataracts

Cataracts - If yes who?(Required)

Heart Condition

Heart Condition - If yes who?(Required)

High Blood Pressure

High Blood Pressure - If yes who?(Required)

Macular Degeneration

Macular Degeneration - If yes who?(Required)

Thryroid Difficulty

Thyroid Difficulty - If yes who?(Required)

Turned or Lazy Eye

Turned or Lazy Eye - If yes, who?(Required)

Retinal Detachment

Retinal Detachment - If yes, who?(Required)

Review of systems

What is your general health?

Date of Last Physical

MM slash DD slash YYYY

Doctor's Name

Past Operation: Kind? When?

Please choose any of the following that applies to you, If it is not listed please explain.

Neurogical

Seizures

Other

Other(Required)

Gastrointestinal

IBS

When?(Required)

Psychiatric

Anxiety

Environmental Allergies/ Medication Allergies

To what?

To what?(Required)

Cardiovascular

Irregular Heartbeat

Other

Other(Required)

Genito-Urinary

Blood/ Lymph

Blood Disorder

Other

Other(Required)

Integumentary

Skin cancer

When?(Required)

Endocrine (glands)

Diabetic? Type I or II

Thyroid difficulty

Other

Diabetic? Type I or II(Required)

Other(Required)

Musculoskeletal

Arthritis

Other

Other(Required)

Ear/ Nose/ Throat

Sinus Trouble

Hard of Hearing

Other

Other(Required)

Respiratory

Asthma

Other

Other(Required)

Current Medications:

Use of Cigarettes/ Tobacoo?(Required)

OCC

Alcohol(Required)

OCC

Other Substances?(Required)

OCC

Eyes, have you ever had any of the following?

Eye surgery

Eye injury

Sensitivity to light

Floaters or spots

Poor distance vision

Poor near vision

Eye infection or disease

Double vision

Flashes

Dry eyes

Pain

Eye strain

Itching/ Burning eyes

Eye fatigue

Sandy, dry or gritty eyes

Eye surgery, when?(Required)

Eye injury, when?(Required)