The South Eastern Eye Center

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:
MM slash DD slash YYYY
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 :
- blurred distance vision
- blurred near vision
- blurred intermediate vision
- trouble seeing the board at school
- frontal headaches
- temporal headaches
- poor focusing ability
- blurry vision at night
- failed school screenings
- failed pediatrician vision screening
- failed other vision screening
- Other
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)*
- double vision
- dryness
- discharge( colored or clear like tears)
- redness
- pink eye
- burning
- itching
- tearing
- foreign body sensation
- sand in the eye
- glare
- light sensitivity
- light flashes
- floaters
- headaches
- pain in eye
- pressure in eye
- trauma (explain below) material in the eye
- sleep with eyes open
- blood in the eyes
- colored spots on the eye
- colored spots on the eyelid
- loss of eyelashes
- eyelash in the eye
- eyelash turned the wrong way
- bump on the eyeball
- bump on eyelid
- other
Explain.
List all medications you take including vitamins:
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
MM slash DD slash YYYY
Sponsor’s Name
Sponsor’s Social Security #
Date of Birth
MM slash DD slash YYYY
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.

The South Eastern Eye Center

Patient History

Emergency Contact

Signature Acknowledgment Section