American Eyecare Burlington Patient History Form

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Responsible Party

  • Date Format: MM slash DD slash YYYY
  • HIPAA Authorization & Release of Medical Information

    I authorize release of any information concerning myself, or my child's health care, advice, and treatment provider for the purpose of evaluation and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me, be made directly to the doctor(s) today and in the future. I acknowledge that I was offered/received a copy of American Eyecare's Notice of Privacy Practices. (If patient is under guardianship, legal guardian should sign as well.)
  • Medical Information

  • Personal/Social History

  • Review of Organ Systems

  • MedicationsDosages 
  • Present IllnessDate diagnosed 
  • Family History

    Please list your blood relatives that have been diagnosed with the following: