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Eye Concepts Vision Center
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2017-07-06T01:14:31+00:00
Eye Concepts Vision Center
How did you hear about us?
PATIENT INFORMATION
Today's Date
MM slash DD slash YYYY
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
Sex
Male
Female
Last 4 of SSN#
Preferred Phone Number
Preferred Phone Type
Cell
Home
Work Phone
Alternate Phone Number
Alternate Phone Type
Cell
Home
Work Phone
Email
Do we have your permission to contact you at the above numbers or email to confirm appointments, recall, let you know your order is ready or for educational information?
Yes
No
Employer
Occupation
If you are a student, name of school/college
INSURANCE INFORMATION
Insurance Co.
Policy or ID#
Group No.
Name of Primary Insured
Date of Birth of Primary Insured
MM slash DD slash YYYY
Employer of Primary Insured
Relationship to Patient
Self
Parent
Spouse
If you will be using insurance, we will file a claim on your behalf. Insurance is not a guarantee of payment and it is ultimately your responsibility to understand your insurance benefits. Your estimated out-of-pocket responsibility is due on the day of service. By signing below you agree to allow Eye Concepts Vision Center and Dr. Karen Simon to submit insurance claims on your behalf and use this authorization in place of your signaturee on submissions to your insurance carrier. In addition you agree to accept financial responsibility for any amount that is not covered or paid by your insurance.
Acknowledgement of Receipt of Notice of Privacy Practice
We are required by federal and state law to maintain the privacy of your health records, and to give you information regarding your right to this information. This notice takes effect January 11, 2014. A copy of our privacy policy is available at the front desk and also on our website. If you would like a copy for your records, please inform any of our staff members and one will be provided for you. By signing below, I acknowledge that I have received or been offered a copy of the notice or Privacy Practices. I understand that Karen S. Simon, O.D. may use and disclose personal health information to provide me with vision care services and treatment, process my vision and insurance claims and to communicate with me as provided in the Notice of Privacy Practices.
What is the reason for the eye examination?
Date of Last Exam
MM slash DD slash YYYY
Location of Last Exam
Health and Eye History
Do any of these Health Conditions apply to you? (Check all that apply)
Developmental Delays
Cancer
Fatigue Syndrome
Other General Health Issues
What other General Health issues do you have?
Ears, Nose & Throat Problems:
Hearing Loss
Sinusitis
Dry Mouth
Laryngitis
Other
Neurological Problems:
Multiple Sclerosis
Epilepsy
Cerebral Palsy
Tumors
Migraine
Autism Spectrum Disorder
Other
Psychological Problems:
Depression
Attention Deficit
Anxiety
Bipolar Disorder
Other
Cardiovascular Problems:
High Blood Pressure
Stroke/CVA
Heart Disease
Vascular Disease
Congestive Heart Failure
Other
Gastrointestinal
Crohn's
Colitis
Ulcer
Acid Reflux
Celiac Disease
Other
Respiratory
Cigarette Smoker
Asthma
Bronchitis
Emphysema
Chronic Obstruction
Sleep Apnea
Other
Genitourinary
Kidney Disease
Prostate Disease/CA
STD
Pregnancy
Other
Endocrine
Type 2 Diabetes
Type 1 Diabetes
Thyroid Disease
Hormone Dysfunction
Other
Skin/Integumentary
Eczema
Rosacea
Psoriasis
Cold Sores
Shingles/Herpes Zoster
Other
Allergic/Immune
Drug Allergies
Environmental Allergies
Rheumatoid Arthritis
Lupus
Sjogren's Syndrome
Other
Hematologic/Lymphatic
Anemia
Large Volume Blood Loss
Ulcer
High Cholesterol
Other
Musculoskeletal
Arthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Osteoporosis
Gout
Other
Are you taking any medication?
Yes
No
List medications you currently take
Are you allergic to any medication?
Yes
No
List medications you are allergic to
Does anyone in your immediate family (parents, siblings or children) have a history of the following:
Diabetes
Glaucoma
Macular Degeneration
Diabetes - Relation to Patient
Glaucoma - Relation to Patient
Macular Degeneration - Relation to Patient
Do you currently use any of the following?
Alcohol
Tobacco
Have YOU been diagnosed with any of the following conditions:
Cataracts
Macular Degeneration
Glaucoma
Diabetes
Diabetic Retinopathy
Dry Eye
Eye Infection
Iritis/Uveitis
Retinal Detachment
Other
List other diagnosis
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