Family Vision Care Intake Form

Patient Name*

First Last

Guardian Name:

First Last

Date*

Birth Date*

Address*

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

Home Phone*

Work Phone

Cell Phone

Email

SS #

Occupation

Gender:*

Male
Female

Marital Status:*

Single
Married
Divorced

Spouse name

First Last

Do you take any medications or vitamins?*

Yes
No

Please list:

Are you allergic to any medications?*

Yes
No

Please list:

Do you or a family member have (sugar) Diabetes?*

Yes
No

Do you or a family member have High Blood Pressure?*

Yes
No

Do you have any other medical conditions?*

Yes
No

Please list:

Do you currently smoke?*

Yes
No

Do you or a family member have Glaucoma?*

Yes
No

Do you or a family member have Cataracts?*

Yes
No

Do you or a family member have Macular Degeneration?*

Yes
No

Have you ever had eye surgery?*

Yes
No

Do you or a family member have a lazy eye or eye turn?*

Yes
No

Do you have problems with dry eye or tearing?*

Yes
No

Do you wear or are you interested in contact lenses?*

Yes
No

Do you suffer from eye allergies?*

Yes
No

What is the reason for today’s visit?

Do you have routine vision insurance?*

Yes
No

Please List:

Do you have medical insurance?*

Yes
No

Please List:

Primary Insured Name:*

First Last

Primary Insured DOB:

Insurance Card Upload

Max. file size: 512 MB.

We will be happy to submit to your insurance for your visit. It is your responsibility to know if your insurance covers the type of office procedures performed and whether referrals are necessary.

I am responsible for all fees, referrals, co-pays, deductibles and non-covered procedures and devices provided. I authorize Family Vision Care to submit to my insurance and assign the benefits to be directly paid to the doctors of Family Vision Care when applicable. I understand that Family Vision Care is fully compliant with HIPAA regulations and privacy issues. I request my professional records/reports only to be released to Family Vision Care when necessary and to release my records to other doctors/professionals who may provide care for me in the future.

1. Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?*

Yes
No

2. Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?*

Yes
No

Signature*

Date*

How did you hear about Family Vision Care?