Anderson Eye Care

ANDERSON EYE CARE
GARY A. ANDERSON, O.D. • LISA M. SLADEK. O.D.
RIVERFRONT PLAZA BUILDING • STE. 10 • 55 CAMPAU AVE. • GRAND RAPIDS, MI 49503-2817
TEL: (616) 459 7380 • FAX: (616) 459 5752 • WWW.ANDERSONEYE.COM

Patient Information

Name

First Last

Preferred Name

Date of Birth

Gender

Male
Female

Marital Status

Single
Married
Divorced

Address

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

Home Phone

Work Phone

Cell Phone

Phone Preference

Home
Work
Cell

Employment

Retired
Student
Employed (indicate where below)

Spouse/Parent

First Last

Email

We will never share your email with anybody.

If you are a new patient, whom can we thank for referring you?

First Last

Insurance Information

IMPORTANT NOTE: Please provide your medical and vision insurance card(s) to the receptionist. If you do not provide us with complete insurance information at the time of your Initial visit, we will be unable to bill your insurance company. You are then responsible for payment at the time of service.

Vision Insurance?

Yes
No

Primary Vision Insurance

Insured Member

First Last

Insured Member Date of Birth

Insured Member's Employer

Secondary Vision Insurance?

Yes
No

Secondary Vision Insurance

Insured Member

First Last

Insured Member Date of Birth

Insured Member's Employer

Medical Insurance?

Yes
No

Primary Medical Insurance

Insured Member

First Last

Insured Member Date of Birth

Insured Member's Employer

Guarantor

Supplemental Medical Insurance?

Yes
No

Supplemental Medical Insurance

Insured Member

First Last

Insured Member Date of Birth

Insured Member's Employer

Guarantor

Medical History

Do you have, or have you ever had, any of the following medical conditions?

Select all that apply

Other (Enter Below)

Ocular History

Select all that apply

Other (Enter Below)

List any medications you are currently taking

(Prescription and over-the-counter, including eye drops)

Do you have allergies to medications?

Yes
No

If yes, please list the medications you are allergic to

Name of your Physician

First Last

Physician's Phone

Social History

Occupation

Hobbies

Check all that apply

Tobacco Use
Alcohol Use
Illegal Drug Use
Exposure to Hepatitis, HIV or TB

Family History

Please note any family (blood relatives) with the following conditions

High Blood Pressure
Glaucoma
Macular Degeneration
Cataracts
Diabetes
Blindess
Heart Disease

By signing below, I verify that the above information is correct. I understand that I am responsible for all financial obligations for health services and for reimbursement and payment of claims from my insurance company.
If, for any reason, the account should become delinquent, I agree to pay for all billing charges, interest charges, collections costs, and reasonable legal fees.

Patient Signature

Today's Date