Bear Eye Center

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

Have your eyes been dilated before?*

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

Our Financial Policy*

Please read our Financial Policy

I understand and agree to this Financial Policy

E-Mail Consent*

Please read our E-Mail Consent Form

I authorize Bear Eye Associates to contact me via e-mail

Privacy Policy*

Please read our Privacy Policy

I understand and agree to the Patient Privacy Policy

Medicare Disclosure*

Please read our Medicare Signature on File form.

I understand and agree to the Medicare Disclosure
I am not currently enrolled in Medicare

Medicare ID number

Visual Field Screening Exam*

Please read our Visual Field Screening Exam Disclosure

I DO want the Visual Field Exam
I DO NOT want the Visual Field Exam