Patient History

Welcome to The South Eastern Eye Center! Please review the information listed below and complete it in its entirety. If information does not pertain to you simply put NA or mark it with NO. Keep in mind that our goal is to see you as efficiently as possible so all appointment concerns will be managed as listed below. Our facility reserves the right to treat medical eye problems as determined by the information provided below. If you have a medical issue but do not provide your medical insurance you will be required to pay for those additional services prior to leaving the office today or you may be asked to return with a referral based on your insurance structure to cover those service needs.

Initial Here

Name

First Last

Address

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

Date of Birth:

Occupation:

Social Security #:

List All Medical Insurance:

Contact Preference: Please number preference order.

Emergency Contact

Name:

Contact:

Relation:

How did you hear about our office: Listed as insurance provider / Newspaper, TV, Radio / White Pages / Yellow Pages / Referred By:

Previous Eye Doctor

Last Eye Exam

Family Doctor

Last Medical Exam

If no changes check here and move to signature acknowledgment section.

No changes

Please tell us if you have the following non-medical eye concerns. Select all that apply :

Explain.

Initial Here. Please tell us if you have the following medical eye concerns. Fees WILL apply in the event treatment of these issues is administered. Treatment for these issues is NOT covered by vision plans and you must present your medical insurance prior to the start of the visit for use. ( Spectera, FEP Blue, Davis Vision, VSP, et c are NOT MEDICAL Insurance PLANS)*

Explain.

List all medications you take including vitamins:

If you are currently pregnant, list how many months?

Are you nursing?

Yes
No

Do you smoke?

Yes
No

Have you ever smoked?

Yes
No

When did you stop?

Do you drink?

Yes
No

How much?

Do you use recreational drugs?

Yes
No

Do you want to be evaluated for contacts?

Yes
No

What type were worn in the past?

Please list if YOU or ANY FAMILY MEMBER has any of the following conditions: DO NOT LEAVE BLANK MARK Yes or No

Autism

Yes
No

Who:

Bone/Joint Disease (arthritis, other)

Yes
No

Who:

Cancer

Yes
No

Who:

Cataracts

Yes
No

Who:

Diabetes

Yes
No

Who:

Last Blood Sugar

A1C

Eye Injuries, You

Yes
No

Explain

Glaucoma

Yes
No

Who:

Heart Disease

Yes
No

Who:

High Blood Pressure

Yes
No

Who:

Last Blood Pressure

High Cholesterol

Yes
No

Who:

Kidney Disease

Yes
No

Who:

Lazy Eye

Yes
No

Who:

Macular Degeneration

Yes
No

Who:

Migraines

Yes
No

Who:

Psychiatric Disease

Yes
No

Who:

Respiratory Problems (asthma, sleep apnea, other)

Yes
No

Who:

Skin Disease

Yes
No

Who:

Stomach Disease

Yes
No

Who:

Surgery, You (eye or in general)

Yes
No

Explain.

Thyroid Disease

Yes
No

Who:

Other Medical/Ocular /Behavior Issues

Yes
No

Who:

Signature Acknowledgment Section

Please Note: Insurance may cover only part of your charges, or may be payable directly to you. Please give any forms or insurance cards to the receptionist in order to process your claim. If your insurance company does not pay as expected, you are ultimately responsible for all charges. Filing your insurance is a courtesy service we provide for our patients.

Your signature below shows your understanding and acknowledgement of our office’s HIPAA documentation. * This signature also authorizes the release and payment of any medical or other information to process claims filed pertaining to services rendered at this office. I understand and agree that professional services are NONREFUNDABLE.

Parent/Patient Signature*

Relation

Date

Sponsor’s Name

Sponsor’s Social Security #

Date of Birth

Method of Payment today: Cash Visa MasterCard Star Card Care Credit Amex

A service charge of 1 ½ % per month, 18% APR may be added to overdue accounts. You will also be liable for legal and collection costs.

*Your signature above is acknowledgement of the fact that you have been given the rights to review a copy of our office’s HIPAA document and non-payment of outstanding balances will be transferred to you and or the guarantor or your command if necessary.