[5527] Premier Eyecare

Name*

First Last

Birthdate*

Social Security Number

Email*

Marital Status*

Address*

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

Home Phone

Cell Phone*

Business Phone

Name of Parent or Spouse*

First Last

Have we examined other members of your family?*

Yes
No

Occupation

Employer

Insurance Company*

Member Name*

First Last

Member DOB*

Member Number*

Name of Family Physician*

First Last

How Did You Find Out About Our Office*

What Is Your General Health Status?*

List All Medications You Are Taking*

Pharmacy Name*

Pharmacy Phone Number*

Medication Allergies*

List All Major Illnesses, Injuries, Surgeries In The Last 10 Years*

Are You Pregnant?*

Yes
No

Name of Last Eye Doctor*

First Last

Date Of Last Eye Exam*

Do You Wear Eyeglasses?*

Yes
No

Do You Wear Contact Lenses*

Yes
No

Current Eyedrops

List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries*

Family History (Family History includes your parents, grandparents, siblings, and your children)*

Do You Use Tobacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Patient Eye Health*

Patient General Health

iWellness Retina Scan: Quick, non-invasive scan that shows the deeper layers of the retina, allowing for earlier detection of eye problems that may affect your vision. This test is recommended for all new patients 35 and older then every 2-3 years afterwards, depending on risk factors. There is an additional fee of $39 for the iWellness Retina Scan. I would like to have the iWellness Retina Scan today.*

Yes
No

NOTICE OF PRIVACY PRACTICES: I have been offered a copy of Premier Eyecare's statement on privacy practices. AUTHORIZATION TO RELEASE INFORMATION: I authorize Premier Eyecare to release any information including diagnosis, records of treatment, or examinations rendered to me or my child during the period of such eye care to 3rd party payers and/or health practitioners. CONSENT FOR TREATMENT: I hereby grant my authorization and consent for medical treatment and procedures for myself and/or minor children as may be necessary for proper health care.*

Yes
No

Payment is expected AT THE TIME OF SERVICE - this includes copays and deductibles from insurance, and any materials purchased for your eyecare needs. We accept cash, debit and credit cards, care credit, HSA, and FSA funds. Any balance resulting from insurance rejections or underpayments becomes patient, parent or guardian responsibility. Any bounced checks will result in a $35 charge. I consent to the financial agreement that Premier Eyecare has stated for any visits I have with their office.*

Yes
No