Wilmette Eye Care

Today's Date

Name

First Middle Last

Address

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

Cell Phone

Home Phone

Work Phone

Gender:

Male
Female

Date of Birth

Social Security Number

Email

Employer

Occupation

Hobbies:

Whom may we thank for referring you to our office?

Insurance Information

Vision Insurance Name

Insured ID#

IS THE RESPONSIBLE PARTY THE SAME AS THE PATIENT INFORMATION ABOVE?

Yes
No

Responsible Party Name

First Last

Responsible Party Date of Birth

Responsible Party Social Security #

Responsible Party Address

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

Patient History

What is the main reason for your visit today?

Please check if you are experiencing any of the following:

If other, please specify

Please check if you have ever experienced the following eye problems:

If other, please specify

Please check if anyone in your family has experienced the following eye problems:

If other, please specify

Have you ever been diagnosed with or have had a significant problem with:

If you selected cancer, please specify what type(s)

If other, please specify

Has anyone in your family every been diagnosed with or have had a significant problem with:

If cancer was selected, please specify what type(s)

If other, please specify

Please list any allergies (environmental or medication) that you may have:

Please give a complete list of medication that you are currently taking (include dosage if known)

Contact Lenses

Do you wear contact lenses?

Yes
No
I used to, but not anymore

Are you interested in being fit for contacts today?

Yes
No

If previous wearer, why did you stop?

Current Brand?

Previous Brand?

How long have you worn contact lenses?

Less than 1 year
2 to 5 years
Longer than 5 years

How often do you replace your contact lenses?

If other, please specify

How many days per week do you sleep in your lenses?

Which solutions do you use?

Aquify
Optifree
Renu
ClearCare
Complete
Generic Brand
Any

Signature

I authorize Wilmette Eye Care to bill my insurance when possible. I understand that the amounts quoted are not a guarantee of benefits and that I may be financially responsible for charges not covered by my insurance. I authorize the use of my signature on all insurance submissions. I acknowledge that I was offered an opportunity to review or requested and received a copy of our Notice of Privacy Practice for HIPAA.

Date