Eyes Plus, Inc.

Patient Information

Date

Name

First Last

SSN

DOB

Home Ph

Wk Ph

Cell

Email Address

Gender

M
F

Best phone contact to reach you is

Home
Work
Cell

Address

Street Address Address Line 2 City State ZIP Code

Current Status

Name of Employer (if a minor, use parent or guardian’s info)

Occupation

Business address

Street Address Address Line 2 City State ZIP Code

Spouse's Name

First Last

Ph

Employer

Occupation

Wk Ph

Person to contact in case of emergency

First Last

Relationship to patient

Ph

How did you hear of us?

Insurance/Responsible Party

Name of person responsible for this account

First Last

Relationship to patient

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name of Employer

Work Ph

Insurance Carrier

Name of Insured

Secondary Insurance Carrier Info

Health History

Name of previous EYE Doctor

Last Exam Date

Does anyone in your FAMILY have a history of the following illnesses?

Do you smoke?

Yes
No

Are you pregnant?

Yes
No

Do you have headaches?

Yes
No

List any ALLERGIES you might have (including medication allergies)

List all MEDICATIONS you are currently taking

Do YOU have a history of the following EYE conditions?

Do YOU currently wear Glasses?

Yes
No

If YES, when?

ALL the time
READING only
DRIVING only

Do YOU currently wear Contacts?

Yes
No

If YES, what BRAND and POWER are they?

What BRAND of SOLUTION(s) are you currently using?

If NO, did you ever wear contacts before?

Yes
No

Are you interested in wearing contacts?

Yes
No

Any other information, inquires, requests or special needs I have

Authorization

I certify that the information given above is to the best of my knowledge. I understand that giving incorrect information could be hazardous to my health. I authorize Dr. Henry Makini of Eyes Plus, Inc. to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to a third party payer and/or health practitioner. I authorize and request my insurance company to remit payment directly to Dr. Henry Makini of Eyes Plus, Inc. otherwise payable to me. I understand that my eye care insurance carrier may pay less than the actual bill for services and I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that Dr. Makini and staff will be contacting me for any necessary follow-up appointments and/or annual visits in an effort to maintain continued quality of care of my visual health needs.

Patient Signature

Date

Responsible Party Signature (if different from above)

Date