Family Eye Care VSP Registration

Name*

First Last

Date of Birth*

Address*

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

Cell Phone*

Work Phone

Home Phone

Email

Emergency Contact Name

Emergency Contact Phone

Occupation

Employer

Date of Last Eye Exam

Were you dilated?

Yes
No

Primary Vision Coverage

Secondary Vision Coverage

Medical Information

How is your general health?

Do you take medications for any of these systems? (Check if Yes)

Notes

Diabetes

Yes
No

Type of Diabetes

Date of Diagnosis

Please list any medications being taken currently

Please list any allergies to medication

Please list any operations

Any other health problems?

Name of family doctor or primary care physician

Date of last visit

Date your blood pressure was last checked

Family History

Please check any that apply

High Blood Pressure
Diabetes
Glaucoma
Macular Degeneration
Retinal Detachment
Cataracts

Personal Eye Information

Do you have any eye conditions or problems?

Yes
No

What kind?

Have you had any eye operations?

Yes
No

Type and Date of Operation

Have you had any eye injuries?

Yes
No

Kind of Injury and Date of Injury

Do you have glaucoma?

Yes
No

Do you have Cataracts?

Yes
No

Do you have dry eyes?

Yes
No

Do you have Macular Degeneration?

Yes
No

Do you have Retinal Detachment?

Yes
No

Do you have blurred vision?

Yes
No

Do you wear glasses?

Yes
No

Do you wear contact lenses?

Yes
No

Type of lens

Additional Information

Consent for Treatment

Dr. Kristie Chevalier is hereby authorized to render services, medication and treatment as necessary. I assume full financial responsibility for any bills incurred. Dr. Kristie Chevalier is a participating Medicare provider.

Insurance Release

l authorize the release of medical information contained my medical records to family physicians and / or insurance companies. A photocopy of this authorization shall be as valid as the original. I assume responsibility for any balance above insurance.

Late/No Show Policy

It is the policy of Family Eyecare & Contact Lens Center, LLC that if a patient misses more than three (3) appointments in 1 year without calling to cancel, they will be made walk-in only. A patient is considered "LATE” if they are more than 15 minutes late for their scheduled appointment. It is at the discretion of the provider as to whether the patient can still be seen as they will need to reschedule.

PAYMENT FOR SERVICES IS EXPECTED AT THE TIME SERVICES ARE RENDERED. ARRANGEMENTS SHOULD BE MADE FOR EXCEPTIONS. ANY ACCOUNT WITH A BALANCE OVER 90 DAYS WILL BE SENT TO COLLECTIONS UNLESS ARRANGEMENTS HAVE BEEN MADE.*

I agree to the privacy policy.

Signature*