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Eyes Plus, Inc.
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2017-07-06T01:14:25+00:00
Eyes Plus, Inc.
Patient Information
Date
MM slash DD slash YYYY
Name
First
Last
SSN
DOB
MM slash DD slash YYYY
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Current Status
Minor
Single
Married
Separated
Divorced
Widowed
Student
Name of Employer (if a minor, use parent or guardian’s info)
Occupation
Business address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Our Website
Other Website
Walk-by
Referral
Insurance/Responsible Party
Name of person responsible for this account
First
Last
Relationship to patient
Phone
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
MM slash DD slash YYYY
Does anyone in your FAMILY have a history of the following illnesses?
Diabetes
Blindness
Cataracts
High Blood Pressure
Thyroid
Lazy Eye
Glaucoma
Heart Disease
HIV
TB
Hepatitis
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?
Had Surgery
Eye Infection
Sensitivity to light
See Spots or Floaters
Flashing lights
Blurred Far Vision
Blurred Near Vision
Dizziness
Nausea
Itchy Eyes
Burning Sensation
Temporary loss of total eyesight in one or both eyes
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
MM slash DD slash YYYY
Responsible Party Signature (if different from above)
Date
MM slash DD slash YYYY
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