Dr. Ashley R. Ford OD, PLLC

Name*

First Middle Last

Address*

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

Home Phone*

Cell Phone

Email*

Patient Employer

Work Phone

Date of Birth*

Sex

Male
Female

SSN

Marital Status

Employment Status

Preferred Language

English
Spanish

Race

Insurance Information

Primary Care Physician

Primary Insurance / ID#

Secondary Insurance / ID#

Is the patient under 18 years of age?

Yes
No

Guardian Information / Authorization

Responsible Party Name

First Middle Last

Date of Birth

SSN

Relationship to Patient

Guardian Address Same as Patient?

Yes
No

Address

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

Phone

Employer

Work Address

I, the above named guardian, authorize Dr. Ashley R. Ford, OD to provide services to the patient named above without my presence (or other designated adult) in the exam room.

Yes
No

List all other adults that may accompany your dependent into the exam room.

Signature

Our office requires payment at time of service unless we "accept assignment" on your insurance. You are responsible if your insurance doesn't pay. We charge 18% per year (1.5% per month) on balances over 30 days old. Contact lens fit and follow up care is billed separately from your eye exam. Your information is protected by our Privacy Policy. I have received a copy of "HIPPA Notice of Privacy Practices" - found online here: http://www.eyedoctorgrandjunction.com/HIPPA_Agreement_NEW2.pdf

Signature*

Date

How did you hear about our office?

Referred By:

General Health History

Do you have any of the following conditions?

Please specify.

Ocular Health History

Have you or a family member ever had any of the following conditions? Please specify family member or self below.

Please specify.

Are you pregnant?

Yes
No

Date of Last Eye Exam

Name of Previous Eye Doctor

What is the reason for your visit today?

Do you experience any of the following?

Do you wear glasses or contacts?

Glasses
Contacts
Both
Neither

Check all that apply regarding your glasses:

Bifocals
Trifocals
Progressives
Transitions
Anti-reflective coating
Sunglasses

What kind of contacts do you wear?

Hard Contacts
Soft Contacts

What is your contact lens replacement schedule?

What kind of contact solution do you use?

Are you interested in trying Contact Lenses?

Yes
No

Are you interested in Refractive Surgery?

Yes
No

Allergies

Please list any medications you are currently taking.

Do you drink?

Yes
No

How often?

Do you smoke?

Yes
No

How often?

Do you have a history of oral Prednisone (steroid) use?

Yes
No