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Eye Clinic, LLC – Sedalia
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2020-01-14T17:47:54+00:00
Eye Clinic, LLC - Sedalia
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The Eye Clinic, LLC
Dr. Kevin K.E. Carl - Dr. Desmon Carl
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Address Line 2
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Whom may we thank for referring you?
Assignment and Release
I hereby authorize payment directly to Dr. Kevin Carl and/or Dr. Desmon Carl of all insurance benefits otherwise payable to me for the services rendered. I understand that I am financially responsible for alt charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize Dr. Kevin Carl and/or Dr. Desmon Carl to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Signature of Responsible Party
Date
MM slash DD slash YYYY
ONE TIME AUTHORIZATION
Name of Beneficiary:
First
Last
HI Claim Number
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Kevin Car1amor Dr. Desmon ar for any services fiimished me by that physician. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agent any information needed to determine these benefits or the benefits payable for related services.
Patient’s Signature
Date Signed
MM slash DD slash YYYY
ACKNOWLEDGEMENT OF RECEIPT
Our Privacy Practice policy is available for anyone who would like a copy, just inform the front desk if you would like a copy. Please sign below even if you choose not to receive a copy of our Privacy Practice policy. I acknowledge that I received a copy of Dr. Kevin Carl and/or Dr. Desmon Carl’s notice of Privacy Practices.
Date
MM slash DD slash YYYY
Patients Name
First
Last
Signature
Please fill out the following to the best of your knowledge.
Name
First
Last
Date
MM slash DD slash YYYY
Last Eye Exam
MM slash DD slash YYYY
Last Eye Doctor
Last Medical Exam
MM slash DD slash YYYY
Current Medical Doctor
Pharmacy
Medical History
Do you have any allergies to medications?
Yes
No
If yes, explain:
List any medications you take (including oral contraceptive, aspirin, over the counter medications, and home remedies):
List all major injuries, surgeries and/or hospitalizations you have had:
Select any of the following that you have had:
Crossed Eyes
Lazy Eye
Glaucoma
Retinal Disease
Cataracts
Eye Injury
Are you Pregnant and/or nursing?
Yes
No
Do you wear glasses?
Yes
No
If yes, How old is your present pair of lenses?
Do you wear contact lenses?
Yes
No
If yes, How old is your present pair of lenses?
Type of contact lenses:
Rigid
Soft
Extended Wear
Other
Are they comfortable?
Yes
No
No Have you had refractive surgery?
Yes
No
Family History
Have any of your relatives, living or deceased, had any of these conditions?
Ocular Disease/Condition
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Select all that apply
Relationship to you
Systemic Disease/Condition
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
Other
Select all that apply
Relationship to you
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Yes, I would prefer to discuss my Social History information directly with my doctor
Do you drive?
Yes
No
If yes, do you have visual difficulty when driving?
Yes
No
If yes, please describe:
Height
Weight
Do you use tobacco products?
Yes
No
If yes, Type/Amount/How long?
Do you drink alcohol?
Yes
No
If yes, Type/Amount/How long?
Do you use illegal drugs?
Yes
No
If yes, Type/Amount/How long?
Have you ever been exposed to or infected with:
Gonorrhea
Hepatitis
HIV
Syphilis
Select all that apply
Review of Systems
Do you currently, or have you ever had any problems in the following areas:
Constitutional
Fever, Weight Loss/Gain
Second Choice
Third Choice
Skin (Integumentary)
Yes
No
Unsure
Neurological
Headaches
Migraines
Seizures
Eyes
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Eye Pain or Soreness
Glare/Light Sensitivity
Chronic infection of eye or lid
Sties or Chalazion
Flashes/Floaters in Vision
Tired Eyes
Endocrine
Thyroid/Other Glands
Ears, Nose, Mouth, Throat
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Vascular/Cardiovascular
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
High Cholesterol
Gastrointestinal
Genitals/Kidney/Bladder
Bones/Joints/Muscles
Rheumatoid Arthritis
Muscle Pain
Joint Pain
Lymphatic/Hematologic
Anemia
Bleeding Problems
Allergic/lmmunologic
Yes
No
Not Sure
Psychiatric
Depression Anxiety
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