New Era Eye Care

Date

Name

First Last

Patient/Guardian Name

Guarantor

Address

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

Date of Birth

Sex

Male
Female

Marital Status

Social Security Number

Phone

E-mail

The e-mail address will be used as your login ID to gain access to your exam and treatment information via the secure patient portal.

Check here if you also wish to receive our office newsletters and promotional offers via this e-mail address

Doctor

Referred By

Magazine
Postcard

Employee Type

Full-time
Part-time
Retired
Unemployed

Employer

Employer Address

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

Patient Record Uses and Disclosures

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means such as sending correspondence to the individual's office instead of the individual's home.

Home Phone Number

Detailed message can be left
Leave message with call-back number only

Other Phone Number

Cell
Work

Detailed message can be left
Lave message with call-back number only

Written Communication

Correspondences can be mailed to my home address
Correspondences should be mailed to the following address:

Address

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

People whom your Medical Information can be disclosed if requested (i.e. Doctor, Spouse, Parents):

Emergency Contact:

Relationship:

Phone Number:

Name:

Relationship:

Name:

Relationship:

Current Medical Problems (Select All That Apply)

Medical History (Select All That Apply)

Please List All Current Medications With Dosage

Medical History (Select All That Apply)

Has Patient's Family Experienced Any of These Medical Conditions? (Select All That Apply)

Any Patient Surgeries? (Select All That Apply)

Has Patient's Family Undergone Any of the Procedures Below? (Select All That Apply)