Hill Country Eye Associates

Today's Date

Name*

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*

Social Security Number

Driver's License #

Occupation

Spouse's Name

Hobbies, Special Interest

History

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

Referred by

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

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.*