Waxhaw Family Vision Care

Today's Date
MM slash DD slash YYYY
Patient Information
Your Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Employer (or School)
Occupation (or Grade)
Spouse (or Parent's Name)
First Last
Date of Birth
MM slash DD slash YYYY
Age
Sex
- Male
- Female
Email
Very Important! New Patients Only:
Who may we thank for referring you to our office?
If not referred, how did you choose our office?
- Another Dr.
- Insurance List
- Saw Sign/Building
- Newspaper/Radio/TV
- Yellow Pages
- Web Page
- Other
Which Web Site or Yellow Pages directory did you find us on?

Or if other, where did you find us? Thanks!
Communication
We currently send appointment reminders and appointment requests using e-mails and/or text messages. We do not release this information to any third parties.
Preferred method of communication.
- E-mail
- Text Messages
- Phone Call only
- E-mail/Text Messages Only
- All of the above
We currently send appointment reminders and appointment requests using e-mails and/or text messages. We do not release this information to any third parties. Please choose one of the following. You may change your preferences at any time.
Insurance Information
Routine Vision Insurance
Subscriber Name
Subscriber ID #
SS#
Subscriber Birth Date
Do you participate in a Flex Spending Account or Health Savings Account?
- Yes
- No
I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment and understand I am responsible for any fee not paid by my insurance.
Signature
Family Eye History
Is there a family medical history of any of the following:
- Blindness
- Cataracts
- Corneal Problems
- Diabetic Eye Disease
- Glaucoma
- Lazy Eye
- Macular Degeneration
- Retinal Problems
Check all that apply.
Patient Medical History
Name of Family Physician
Town where located
How long has it been since your last physical?
Please list all medications you are currently taking including eye drops, vitamins, birth control, and over the counter.
Please list any allergies to medications.
Write none if none known.
How long has it been since your last eye exam?
Please list any previous eye injuries or surgeries.
Have you ever experienced, been diagnosed, or treated for any of the following?
- Blurry Vision
- Doubly Vision
- Crossed/Lazy Eye
- Floaters
- Flashes of Light
- Dry Eyes
- Burning Eyes
- Itchy Eyes
- Tearing
- Cataracts
- Glaucoma
- Macular Degeneration
- Retinal Detachment
- Corneal Abrasion
- Sunlight Sensitivity
- Trouble seeing at night
- Eye Surgery
- Eye Injury
- Other eye disorders
Please describe eye disorder(s) not listed?
Have you ever been diagnosed or treated for the following health problems?
Allergies
- Yes
- No
Arthritis
- Yes
- No
Blood/Lymph
- Yes
- No
Bronchitis
- Yes
- No
Cancer
- Yes
- No
Cholesterol
- Yes
- No
Diabetes
- Yes
- No
Digestive
- Yes
- No
Ears/Nose/Throat
- Yes
- No
Endocrine
- Yes
- No
Eczema/Rashes
- Yes
- No
Fatigue
- Yes
- No
Fevers
- Yes
- No
Genitourinary
- Yes
- No
High Blood Pressure
- Yes
- No
Integumentary (Skin)
- Yes
- No
Kidney
- Yes
- No
Kidney
- Yes
- No
Muscle/Bone
- Yes
- No
Neurological
- Yes
- No
Psychological
- Yes
- No
Respiratory
- Yes
- No
Sinus
- Yes
- No
Throat Infections
- Yes
- No
Thyroid
- Yes
- No
Unusual weight losses/gains
- Yes
- No
Missed Appointment and Cancellation Policy
Due to an increased number of missed appointments and last minute cancellations Waxhaw Family Vision Care finds it necessary to change our current missed appointment policy. We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment in a timely manner, you may be preventing another patient from getting a much needed appointment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seeming "full" appointment book. As of February 1, 2014, the new policy will be: If an appointment is missed and has not been cancelled at least 24 hours in advance you will be charged a twenty five dollar ($25) fee; this will not be covered by your insurance company and is non-refundable. We reserve the right to dismiss patients from our practice after three missed appointments. Also, we understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient arrives 15 minutes past their scheduled appointment time, it will be considered a missed appointment. The $25.00 fee will apply and we will have to reschedule the appointment.
Missed Appointment and Cancellation Policy Signature*
Contact Lens Exam/Fitting Policy
If you are a contact lens wearer or would like to be fit with contact lenses, there is a contact lens exam/ fitting fee in addition to your regular exam fees. This runs $39.00 to $149.00 depending on the level of care and time involved (typically $39.00 if there are no changes). This fee will automatically be charged to your annual exam to update your contact lenses prescription. Your routine vision insurance may or may not pay toward this; however, you are responsible for this fee at the time of service. If you do not wish to update your contact lens Rx, it is your responsibility to let us know before your examination.
Contact Lens Exam/Fitting Policy Signature*
Notice of Privacy Practices (HIPPA)
Please Click Here to Read our HIPPA Policy
By Signing Here I am Stating that I Have Read and Understand the Above HIPPA Policy*

Waxhaw Family Vision Care

Patient Information

Very Important! New Patients Only:

Communication

Insurance Information

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment and understand I am responsible for any fee not paid by my insurance.

Family Eye History

Patient Medical History

Have you ever been diagnosed or treated for the following health problems?

Missed Appointment and Cancellation Policy

Contact Lens Exam/Fitting Policy

Notice of Privacy Practices (HIPPA)