J Clay Simmers OD

Today's Date

Patient's name

First Last

Birth Date

Age

Male/Female

Male
Female

Address

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

If PO Box, please list the street address.

Social Security Number

Employer

Home Phone

Cell Phone

Work Phone

Email Address

Spouse, Parent (If Patient is under 18) or Responsible Party Information

Spouse/Parent's Name

First Last

Birth Date

Social Security Number

Address (if different from patient's)

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

Cell Phone

Work Phone

Employer

Do you have vision coverage?

Yes
No

List any medications you are currently taking.

List any medications you are allergic to.

Have you or any blood relative had any of the following conditions? Please check:

Glaucoma

Yourself
Relative
Neither

Cataracts

Yourself
Relative
Neither

Macular Degeneration

Yourself
Relative
Neither

Dry Eyes

Yourself
Relative
Neither

Thyroid

Yourself
Relative
Neither

High Blood Pressure

Yourself
Relative
Neither

Diabetes

Yourself
Relative
Neither

Systemic Lupus

Yourself
Relative
Neither

Other Systemic Disease

Yourself
Relative
Neither

Are you pregnant?

Yes
No

What is the main reason for your visit?

Patient Consent for Privacy Practices

Our notice of privacy practices provides information about how we may use and disclose protected health information about you. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care.

Signature

Date

Patient Consent for Insurance Authorization

I authorize my healthcare provider to affix my name to all insurance submissions, documentations, and information relation to any and all health benefits due to my dependents and me. This agreement expires one year from today.

Signature

Date