Professional EyeCare Associates

Name
Date of Birth
Address
Race
Please mark up to two choices
Ethnicity

Insurance Information

Patients must provide insurance card prior to exam
Vision Carrier
Vision Carrier
Subscriber Date of Birth(Required)
Vision Carrier
Vision Carrier
Medical Carrier
Medical Carrier
Subscriber Date of Birth(Required)
Medical Carrier
Medical Carrier
Is your billing informaion the same as the address above?
Address

Individuals with whom we may share medical information

Name
Is this person an Emergency Contact?
Name
Is this person an Emergency Contact?
Name
Is this person an Emergency Contact?

Financial Agreement / Authorization to Treat

Financial Agreement: I understand that I am responsible for payment of covered and noncovered services (as quoted by the insurance company). In cases where professional goods and services are not covered(denied) by your insurance company, it will be the patient's responsibility to pay for these services. I understand Professional EyeCare Associates may release my information to process all claims for reimbursement on my behalf. Authorization to Treat: I authorize Professional EyeCare associates to furnish optometric care and services, including but not limited to: diagnostic tests, examinations, and other procedures which are deemed necessary in the course of my care.
Date

PRIVACY ACKNOWLEDGMENT

Notice of Privacy Practices: I acknowledge, by my signature below, that I have been given the opportunity to review the Notice of Privacy Practices and I understand that I may request a copy of this notice should I so choose.
Notice of Privacy Practices
Date
Please check the box below if you wish to decline.

Please complete this form as accurately and completely as possible.

MM slash DD slash YYYY
Patient's Name
Patient's Date of Birth
Optional
Optional
Please list all current medications, including eye drops and non-prescription medications
Please list all allergies to medications or foods and seasonal allergies
Please list all dates and type of surgery including eye surgery

Please indicate if you (the patient) or a family member ever had the following conditions:

Amblyopia, crossed or lazy eye?
Cataracts?
Eye Infection?
Eye Injury?
Glaucoma?
Macular degeneration?
Cardiovascular issues?
(high blood pressure, high cholesterol, heart disease, arrhythmia, cancer, etc.)
Endocrine issues?
(diabetes, high/low thyroid, cancer, etc.)
Neurological issues?
(stroke, numbness, weakness, headaches, paralysis, seizures, cancer, etc.)
Ear, nose, mouth/throat issues?
(hearing loss, sinus problems, sore throat, cancer, etc.)
Gastrointestinal/liver issues?
(heartburn, abdominal pain, cirrhosis, hepatitis, cancer, etc.)
Genital/urinal issues?
(discharge, pain, blood in urine, cancer, etc.)
Blood or lymph issues?
(anemia, leukemia, HIV/AIDS, cancer, etc.)
Skin issues?
(rashes, excessive dryness, non-healing sores, cancer, etc.)
Musculoskeletal issues?
(muscle aches, joint pain, swollen joints, arthritis, cancer, etc.)
Psychiatric issues?
(depression, anxiety, etc.)
Respiratory issues?
(wheezing, cough, asthma, tuberculosis, bronchitis, cancer, etc.)
Autoimmune diseases?
(Lupus, Crohn's disease, etc.)
Recent fever for more than 10 days, unexpected weight loss or gain, fatigue?
Other conditions not mentioned above?
Do you currently smoke or vape, or have you ever smoked?
Date