Buckingham Eye Associates

Preferred Salutation

Dr.
Mr.
Mrs.
Ms.
Miss
Reverend

Gender

Male
Female

Name

First Middle Last

Birth Date

Marital Status

Address

Street Address Address Line 2 City State ZIP Code

Residence Phone

Social Security #

If Minor, Parent Name

First Last

Employer

Occupation

Business Phone

Email Address

Spouse Name

First Last

Date of Birth

Social Security #

Employer

Occupation

Business Phone

Email Address

Insurance Information

We require all insurance information prior to services being provided. Due to the diverse nature of many eye conditions, disorders, and procedures, many of the services we provide are covered by your MAJOR MEDICAL INSURANCE rather than routine vision coverage. Please provide us with the following information even if you believe that you are seeing us for a non-medical reason.

Medical Insurance Company

Policy #

Group #

Subscriber Name

First Last

Secondary Insurance Company

Policy #

Group #

Subscriber Name

First Last

Referral Information

How did you learn about our office? (Please check all sources that apply.

Relative
Friend
Yellow Pages
Doctor Referral
HMO - Insurance
Location
Newspaper
Other

List family members (relationship) who are patients in this office

If you are a new patient, who may we thank for referring you to this office?

Please provide us with the name and telephone number of your Primary Care Physician

I authorize the release of any medical or other information necessary to process any claims arising from services and materials provided. I also request payment of government or private insurance benefits to the physician accepting assignment for service and materials provided. I also understand that I assume all financial responsibility for this account for any amounts due, regardless of insurance coverage.

Signature

Date

Relationship to Patient.

About Your Eyes

What specific problem with your eyes, if any, caused you to schedule an appointment with our office?

Do You Frequently Experience/Have:(Please check all that apply)

If You Marked Other, Please describe:

Do you presently wear or have been prescribed glasses?

Yes
No

If so, how often?

Do you presently wear contacts?

Yes
No

If so, what type?

Do you currently use any drops or medication for your eyes?

Yes
No

If so, please list:

If you or a blood relative have experienced any of the following, check all that apply and indicate who in the next section:

Eye Injury
Cataracts
Amblyopia/Lazy Eye
Eye Operation
Eye Disease
Blindness
Turned or Crossed Eye
Glaucoma
Other

Who experienced what you marked above?

Does your job require the use of a computer?

Yes
No

How many hours per day?

About Your General Health

How would you describe your general health?

Excellent
Average
Poor

When was your last physical examination?

Physician's Name

If you or a blood relative have any of the following, check all that apply and indicate who:

High Blood Pressure
Thyroid Problems
Cancer
Low Blood Pressure
Diabetes
Hypoglycemia
Epilepsy or Convulsions
Heart Problems
Sexually Transmitted Disease

Indicate who the above applies to:

Are you presently or have you recently been taking any prescription or non-prescription medications? Please list them:

Do you have any allergies, or are you allergic to any medications? Please list them:

Female patients, if you are currently taking oral contraceptives or hormonal supplements, please indicate length of Rx history:

If you are pregnant, please indicate how many months: