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Irvine Eye Physicians and Surgeons
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2017-07-06T01:14:31+00:00
Irvine Eye Physicians and Surgeons
Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Title
First
M.I.
Last
Date of Birth
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Sex
Address
Street Address
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Congo, Republic of the
Cook Islands
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Guinea
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Isle of Man
Israel
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Japan
Jersey
Jordan
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Kenya
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Lao People's Democratic Republic
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Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
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Martinique
Mauritania
Mauritius
Mayotte
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Daytime Phone
Cell Phone
Email
Social Security No.
Marial Status
*
Single
Married
Widowed
Divorced
Name of Employer
Occupation
Employer Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
If child, parent's or guardians' name
Relationship
If married, name of spouse
Souse DOB
MM slash DD slash YYYY
Person financially responsible for this account
Primary Insurance Name
Insured I.D. Number
Policy Group No.
Policy Holder's Name
Policy Holder's DOB
Plan Name
Secondary Insurance Name
Insured I.D. Number
Policy Group No.
Policyholder's Name
Policyholder's DOB
Plan Name
Nearest relative or friend not residing with you
Relationship
Phone
How did you hear of us?
phone book
insurance list
internet
friend/family
physician office
other
What is your chief complaint?
I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.
*
I hereby authorize the use or disclosure of my individually identifiable health information as described in the “NOTICE OF PRIVACY PRACTICES” document.
Date
MM slash DD slash YYYY
What is your general health?
Excellent
Good
Fair
Poor
Do you have problems with any of these symptoms? (Check all that apply.)
Gastrointestinal
Nervous
Endocrine (glands)
Ears/Nose/Throat
Urinary
Blood/lymph
Cardiovascular
Muscles/bones
Respiratory
Integumentary (skin)
Headaches
High blood pressure
Eyes
Mental
Diabetes
Type of diabetes and date of diagnosis
Please explain above
Do you smoke?
Yes
No
Alcohol intake?
Yes
No
Allergies to medication?
Yes
No
Which medications?
Current medications (If none, leave blank)
Have you had any operations / surgery?
Yes
No
What kind?
Name of Family Doctor
Family History (Check all that apply)
High Blood Pressure
Macular Degeneration
Diabetes
Retinal Detachment
Glaucoma
Cataracts
High Blood Pressure - Relation to Patient
Macular Degeneration - Relation to Patient
Diabetes - Relation to Patient
Retinal Detachment - Relation to Patient
Glaucoma - Relation to Patient
Cataracts - Relation to Patient
Date of last eye exam
MM slash DD slash YYYY
Do you have any eye conditions or problems?
Yes
No
What kind?
Have you had any eye operations?
Yes
No
Type and Date
Have you had an eye injury?
Yes
No
Kind of Injury and Date
Do you have: (Check all that apply)
Glaucoma?
Cataracts?
Dry Eyes?
Macular Degeneration?
Retinal Detachment?
Blurred Vision?
Do you wear: (Check all that apply)
Glasses
Contacts
Type of Lens
Soft
Hard
Average contact lens daily wear time
<6 hrs
6 - 10
10 - 14
14 - 18
Overnight
Extended Wear
Average contact lens wear number of days per week
Additional Information
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