The EYE CARE Team

HIPPA - Notice of Privacy Practices Acknowledgement

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Signature

Patient Information

Name*

First Middle Last

Date of Birth*

SSN

Sex

Male
Female

Race

Indian or Native
Black / African
Hawaiian / Pacific Islander
Asian
White
Hispanic

Address

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

Home Phone

Cell Phone

Work Phone

Email

Occupation

Employer or School

Referred By:

Please specify:

Insurance Subscriber

Person Responsible for Payment

Self
Spouse
Parent
Guardian

Name

First Last

Date of Birth

Address same as patient?

Yes
No

Address

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

Phone

Employer

Financial Responsibility and Assignment of Insurance Benefits

**If we are billing insurance for you, please provide the front desk with your insurance card/information.** I hereby authorize my insurance benefits to be paid directly to the doctor and/or The Eye Care Team, and I agree that I am financially responsible for any non-covered services.

Signature*

Today's Date*

Vision History

What is the primary reason for your visit?

How long ago was your last eye exam?

1 year
2 years
3 years

Do you wear glasses?

Yes
No

Do you wear contact lenses?

Yes
No

Have you had refractive surgery? (LASIK, PRK, Radial K)

Yes
No

Which of the following activities/hobbies do you encounter?

Medical History

Primary Care Physician (PCP)

PCP Phone

Please list your current medications.

Please list your medication allergies.

Have you been treated for any eye disease(s) in the past?

No
Glaucoma
Cataracts
Macular Degeneration
Iritis
Eye Injuries
Eye Allergies
Eye Infection
Strabismus (lazy eye)

Do you currently have problems with any of the following?

Please list any other medical problems.

Have you even been treated for cancer of any type?

Yes
No

Specify

Do any of your blood relatives have glaucoma?

Yes
No

Specify

Do any of your blood relatives have macular degeneration?

Yes
No

Specify

Do any of your blood relatives have Diabetes?

Yes
No

Specify

Tobacco use

None
Former Smoker
<1 pack per day
1-2 packs per day
>2 packs per day

Alcohol use

Never
Socially
1-2 drinks daily
Above average use
Alcohol dependence

Have you had a blood transfusion?

Yes
No

Are you pregnant?

Yes
No

Additional comments or concerns?