Tharp Patient Forms

Date

Name

First Middle Last

Name you prefer to be called

Age

Date of Birth

Sex

M
F

Race

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Email

May we text or email you?

Yes
No

Occupation

Employer

Emergency contact name

Emergency contact number

Whom may we thank for referring you?

Do you have any medical problems?

Yes
No

Do you take any medications?

Yes
No

Are you allergic to any medications?

Yes
No

Have you ever had any eye diseases, eye injuries, or eye surgeries?

Yes
No

Have you ever had any surgeries?

Yes
No

Do you have a family history of any eye disease?

Yes
No

Do you smoke?

Yes
No

Do you currently wear contact lenses?

Yes
No

Are you interested in contact lenses?

Yes
No

Do you have any medical insurance?

Yes
No

Do you have any vision insurance?

Yes
No

Are you pregnant?

Yes
No

Are you nursing?

Yes
No

Dilating the pupils with eye drops is recommended for most patients every one to two years. Pupil dilation helps the doctor perform a more thorough eye health exam and can provide for earlier diagnosis of some vision or life threatening conditions. It is advisable to use caution for about 4 hours due to side effects that include light sensitivity, blurred vision, and poor depth perception. This service is in addition to the eye examination and is an additional $20.

I want to have my eyes dilated today.

Yes
No

Payment is due when services are rendered. What form of payment will you be using today?

Cash
Check
Credit Card
Debit Card

I have read/received a copy of Notice of Privacy Practice.

Signature of patient or responsible party

Date

I have read/received a copy of Notice of Privacy Practice.

We appreciate you. Thank you for trusting us with your eye care needs.