Advantage Eyecare New Patient

Today's Date

Name

First Middle Last

Address

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

Date of Birth

Sex

Male
Female

Home Phone

Work Phone Number

Cell Phone

Is it okay to TEXT reminders for appointments or to notify you that your order is in?

Yes
No

Email

** Emails will be used to confirm appointments, notify of orders, to notify of special promotions and to pass along eye health information.

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
Native Hawaiian/other Pacific Island

Race

White
Asian
Black

Language Preference

English
Spanish

Family Members that are patients

Name	Do they live with you?	Date of birth	Relationship

Insurance Information

Who is the cardholder of the insurance?

Date of birth

Employer

Cardholder Social Security

Address of Cardholder

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

If not the same as the patient

Cardholder's Phone Number

Cardholder's Alternate Phone Number

Your Ocular History

Date of Cataract Surgery on Left Eye

Date of Cataract Surgery on Right Eye

Date of Cataract Surgery on Both Eyes

Describe your eye injury

Describe your eye disease

Describe your eye surgery

Describe your "Other" ocular history

Family History

Cataracts
Lazy Eye
Macular Degeneration
Glaucoma
Other Eye Diseases
Diabetes
Cancer

Describe your Family History of "Other Eye Diseases"

Please Specify the type of Cancer in your Family History

Please Describe any Other Conditions in your Family History

List your current medications

Name of medication	Dosage	Taken how often?	Reason prescribed

If you take more than one medication, please use the plus symbol to the right of the field to enter more.

List your medication allergies

If you have more than one non-medication allergy, please use the plus symbol to the right of the field to enter more.

List other Non-Medication Allergies

Review of Systems

Cardiovascular

Constitutional

persistent symptoms of:

Hematologic/Lympatic

Endocrine

Type of Diabetes

How many years have you had diabetes

Genitourinary

Gastrointestinal

Head

Integumentary

Immunologic

Respiratory

Musculoskeletal

Neurological

Psychiatric

Are you a smoker?

Yes
No

If you are a smoker, how much, and how long have you smoked?

How much?	How long?

Have you ever smoked?

Yes
No

How long ago did you quit smoking?

I authorize Dr. Rutan to release to my insurance carriers, including Medicare, Medicaid, and Medicare Supplements to provide any information required to resubmit any denied or incorrectly paid claims. This authorization remains in effect until withdrawn by me*

Signature

Date

I acknowledge that I received a copy of Charles H. Rutan O.D.'s Notice of Privacy Practices

Signature

Date

Name of person responsible for the account

First Last

Date of birth

Address

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

Social Security Number

Relationship to patient

Phone Number

Signature*

Date

Advantage Eyecare New Patient Form

Insurance Information

Review of Systems