Dr. Richard Zobel

Patient Information

Name*

First Middle Last

Date of Birth*

Address*

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

Home Phone

Work Phone

Cell Phone

Email

Referred By:

Vision/Medical Insurance Information

It is the patient's responsibility to inform the front desk of any changes to insurance.

Occupation/Employer

Insurance Provider

Subscriber ID or SSN

Medical History

Patient's Medical History

Diabetes
Cardiovascular Problems
Respiratory Problems
High Cholesterol
Skin Conditions
Psychological
Endocrine (Glands)
High Blood Pressure
None of the above

Check all conditions that apply.

Height (feet/inches)

Weight (lbs)

Family Medical History

High Blood Pressure
Macular Degeneration
Diabetes
Retinal Detachment
Glaucoma
Cateracts
None of the above

If You Selected Any Conditions, Please Specify Family Member Below

Ocular History

Eye Operations
Eye Injuries
Glaucoma
Cateracts
Dry Eye
Glasses
Contact Lenses
None of the above

If You Checked "Eye Operations" or "Eye Injuries" Please Specify Type and Date Below

Date of Last Eye Exam

Current Medications

Medication Allergies

Smoker?

Yes
No

Consumes Alcohol?

Yes
No

If "Yes", how many drinks per week?

Name of Primary Care Physician

Primary Care Physician Phone

Patient Signature

I hereby grant permission for Dr. Richard Zobel to exchange information with my insurance company concerning my history/results of my examination/diagnosis/treatment. I hereby assign all medical benefits to which I am entitled. I understand that I am financially responsible for all charges whether paid by said insurance or not. It will be the patient's responsibility to provide our office with any required referrals. I authorize this office to release any information needed to determine the benefits for related service. Patients without insurance are responsible for all charges at time of visit.

Patient Signature*

Date*