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Hill Country Eye Associates
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2017-10-25T21:19:39+00:00
Hill Country Eye Associates
Today's Date
MM slash DD slash YYYY
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
Male
Female
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Cell Phone
Work Phone
Email
*
Birthday
*
MM slash DD slash YYYY
Social Security Number
Driver's License #
Occupation
Spouse's Name
Hobbies, Special Interest
History
Diabetes
Light Flashes
Eye/Head Injury
Glaucoma
Headaches
Thyroid Disease
Hypertension
Heart Disease
Cataracts
Floaters
Lazy Eye
Allergies
Dry Eye
Double Vision
Eye Muscle Problems
Please list any history that wasn't included in the list above
Medications and/or Nutritional Supplements (List name and purpose):
Are you wearing or have you ever worn or tried contact lenses?
Yes
No
If not, are you interested in contact lenses?
Yes
No
In Case of Emergency Contact Name
First
Last
Phone
Primary Care Physician:
Date of Last Visit
MM slash DD slash YYYY
Referred by
Phone Book
Insurance
School
Drive By
Advertisement
Patient
Doctor
If "Patient" or "Doctor" was listed above, please provider their names
Insurance Provider
ID #
Group #
Name of Primary Person on Insurance
Date of Birth of Primary Person on Insurance
MM slash DD slash YYYY
If patient is a child or adolescent, please complete the following. All others, please go to next section.
Parent or Legal Guardian
First
Last
Relationship to patient
Mother
Father
Cell Phone
Work Phone
Employer
Child's School
Grade
INFORMED CONSENT AND TREATMENT AUTHORIZATION (For all patients)
I authorize Hill Country Eye Associates to leave a message with available persons, at my home phone number, on my answering machine or with the emergency contact listed above.
*
Yes, I authorize
No, I do not authorize
I authorize Hill Country Eye Associates to leave a message at my place of employment.
*
Yes, I authorize
No, I do not authorize
I hereby authorize the release of all necessary Protected Health Information and assign all medical and vision benefits to Hill Country Eye Associates. I request that you file my insurance but do understand that I am ultimately responsible for any bill incurred in this office.
*
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