Lake Union Vision Clinic

Today's Date:

Full Name:

First Last

Gender:

Address:

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

Social Security Number:

Birth Date:

Age:

Home Phone:

Work Phone:

Cell Phone:

Email:

Best Way to Contact You:

Home Phone
Work Phone
Cell Phone
Email

Marital Status:

Single
Married
Divorced
Widowed

Hobbies:

Occupation:

Emergency Contact:

First Last

Emergency Contact Phone Number:

Who may we thank for referring you to us?

May we add you to our office Facebook page?

Yes
No

May we contact you via email?

Yes
No

Responsible Party (if different from above)

Name of person responsible for account if not the patient:

First Last

Address:

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

Home Phone:

Work Phone:

Cell Phone:

Employer:

Relationship to patient:

Insurance Information

Insurance:

Group Number:

Subscriber:

ID Number:

Patient's Relationship to Subscriber:

Self
Spouse
Child
Dependant

Subscriber's Employer:

Subscribers date of birth:

Please Read and Sign Below

We will be happy to bill your insurance for you as a courtesy provided that you bring your insurance card with you to your visit. You may also submit insurance claims yourself. We must also emphasize that as your eye care providers, our relationship is with you, not your insurance company, with whom we have no legal relationship. While the filing of insurance claims is a courtesy we extend to our patients, all charges (deductible amount, co-insurance, or any balance not paid by your insurance company) are your responsibility from the date the services are rendered. If we are not billing your insurance, you are financially responsible for all services from the date the services are rendered. Questions or concerns regarding charges, insurance coverage or benefits will be addressed with the office manager or any other staff members, not with the doctor. I acknowledge that I have completed all of the information to the best of my knowledge. I authorize the eye doctor to release any I acknowledge that I have completed all of the information to the best of my knowledge. I authorize the eye doctor to release any information about my records to pertinent third party payers and/or other health practitioners if needed. Lastly, I understand that information about my records to pertinent third party payers and/or other health practitioners if needed. Lastly, I understand that returns and/or exchanges of any eyewear, as seen necessary by a staff member, will be done so by office credit and no refunds returns and/or exchanges of any eyewear, as seen necessary by a staff member, will be done so by office credit and no refunds will be given. Any eyewear returns or exchanges may be subject to a restocking fee.

Signature

Date
Date Format: MM slash DD slash YYYY

Medical History

Are you having difficulties with your vision?
Yes
No

What type of difficulty?
Distance
Intermediate
Near

Do you wear glasses?
Yes
No

How old is your current pair of glasses?

How old are your prescription sunglasses?

How old are your back up glasses?

Do you spend any time on the computer?
Yes
No

How long per day?

Do you wear contact lenses?
Yes
No

What type of contact lenses do you wear?
Gas Permeable
Soft
Extended Wear
Disposable
Overnight

If you wear disposable lenses, how often do you replace them?

What solution do you use to clean your contact lenses with?

Please check any of the following you have had:
Crossed Eyes
Lazy Eye
Droopy Eyelid
Protruding Eye/s
Glaucoma
Retinal Disease
Cataracts
Eye Infection
Eye Injury
Eye Surgery

Personal Medical History

List any medications that you take. Please include over the counter meds, oral contraceptives, aspirin, and home remedies.

Do you have any allergies to medications?
Yes
No

Please list the medication/s.

Please list all major surgeries, injuries, and/or hospitalizations you have had.

Women, are you pregnant or nursing?
Yes
No

Please note any general medical history for the following conditions.

Respiratory problems
Yes
No
Shortness of breath, cough, etc.

Chronic fatigue, fever, unexpected weight gain/loss
Yes
No

Ear, nose, or throat problems
Yes
No

Skin conditions
Yes
No
Rashes, dryness.

Musculoskeletal problems
Yes
No
arthritis, muscle pain.

Heart problems
Yes
No
Disease, blood pressure, irregular beat.

Cancer
Yes
No

Diabetes
Yes
No

High Cholesterol
Yes
No

Kidney Disease
Yes
No

Live Disease
Yes
No

Thyroid Disease
Yes
No

Neurologic problems
Yes
No
Numbness, paralysis, headache

Psychiatric problems
Yes
No
Depresstion, anxiety.

Other

If you checked yes on any of the fields above, please explain here.

Family History

Are there any medical or eye diseases that run in the family?
Yes
No
Heart disease, diabetes, cancer, glaucoma, macular degeneration, etc.

If yes, please specify.