Blaine Family Eye Care Ltd

Medical Information

Patient/Guardian Name

First Last

Date of Birth

Current Medical Problems

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Medical History

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Allergies to Medications: Please List

All Current Medications

Please List with Dosage

Patient Eye History. Select all that apply

Other: Please Specify

Has Patient's Family Experienced Any of These Medical Conditions? Select all that apply.

Other: Please Specify

Any Patient Surgeries? Select all that apply.

Other: Please Specify

Has Patient's Family Undergone Any of The Procedures below? Select all that apply.

Other: Please Specify

At Blaine Family Eye Care we keep a record of the health care services we provide to you. You may request a copy of your medical record in writing or get more information by contacting our privacy officer. We will not disclose your record to others unless you direct us to do so or unless legal authorities authorize or compel us to do so. Our Notice of Privacy Practices is available at the reception desk. The Notice describes in greater detail how your health information may be used or disclosed, and how you can access your information. You are entitled to a copy of this Notice and it is available at your request.

Consent

I agree to the privacy policy.

I acknowledge the Notice of Privacy Practices has been offered to me and is readily available in accordance with the Health Insurance Portability and Accountability Act.

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