Www.visionprooptical.com
[pic]
|Contact Information |
|First Name |_____________________________ |Street Address |_____________________________ |
|Last Name |_____________________________ |Suite/Apt. |_____________________________ |
|Daytime Phone |_____________________________ |City |_____________________________ |
|Mobile Phone |_____________________________ |State |_____________________________ |
|Email |_____________________________ |Zip Code |_____________________________ |
| | | | |
|Patient Information |Vision Insurance Information |
|Gender |_____________________________ |Provider Name |_____________________________ |
|Date of Birth |_____________________________ |Provider Phone |_____________________________ |
|Occupation |_____________________________ |Policy/I.D. # |_____________________________ |
|Employer |_____________________________ |Group # |_____________________________ |
| | | | |
|Primary Insurance Information |Secondary Insurance Information |
|Provider Name |_____________________________ |Provider Name |_____________________________ |
|Provider Phone |_____________________________ |Provider Phone |_____________________________ |
|Policy/I.D. # |_____________________________ |Policy/I.D. # |_____________________________ |
|Group # |_____________________________ |Group # |_____________________________ |
| | | | |
|Account Responsible (if patient is under 18) |
|First Name |_____________________________ |Street Address |_____________________________ |
|Last Name |_____________________________ |Suite/Apt. |_____________________________ |
|Date of Birth |_____________________________ |City |_____________________________ |
|Daytime Phone |_____________________________ |State |_____________________________ |
|Mobile Phone |_____________________________ |Zip Code |_____________________________ |
|Email |_____________________________ | | |
| | | | |
|Privacy & HIPAA |
|If you would like us to disclose any information about your medical condition, material orders or balances due with anyone else, please provide their |
|information below. You can revoke this |
|permission in writing at any time. |
|Full Name _______________________________ Relationship to patient _______________ |
| |
|Please sign to indicate that you are aware that our office complies with HIPAA, the Health Information Portability and Accountability Act. Please let us know if|
|you would like a copy for your records. Your signature below will be valid until we update our HIPAA policy or you revoke your signature in writing toVision |
|Pro. |
|Signature ____________________________________________________ Date _______________ |
| |
|Payment and Insurance Agreement |
|Outstanding balances are subject to collection activities. Balances over 90 days will be subject to a collection fee equal to 30% of the balance due and will be|
|forwarded to an outside collection agency. |
| |
|I authorize release of information, including treatment and protected health information to my insurance company that is needed to process payment for services.|
|I authorize my insurance carrier to pay benefits for services rendered, directly to Vision Pro Optical. I have read and agree to the terms of the above |
|information. I understand payment is expected at the time services are rendered and that I am responsible for any balance insurance determines is my |
|responsibility. |
| |
|Signature ____________________________________________________ Date _______________ |
|Vision History (please check all that apply) |
| None |\ Fluctuating vision | Mucous discharge |
|Macular Degeneration |Loss of vision |Redness |
|Cataract(s) |Halos |Sandy or gritty feeling |
|Cataract Surgery |Dryness |Sensitivity to light/glare |
|Glaucoma |Eye pain and/or soreness |Strabismus (crossed eye) |
|Amblyopia (lazy eye) |Floaters or spots |Tired eyes |
|Blurred vision at a distance |Infection of eye or lid |Watery eyes |
|Near vision issues |Itching |Lasik |
|Double vision |Loss of peripheral vision |Burning |
|Drooping eyelid(s) | | |
| | | |
|Contact Lens History (if applicable) |
|Brand of current contacts |_______________________ |How often are they replaced? |_______________________ |
|Age of current contacts |_______________________ |Which solution do you use? |_______________________ |
| | | |
|General Medical History | |
|When (approx.) was your last eye exam? ____________________________ |Do you have any of the following? |
| |None |
|Are there any concerns that brought you here today? ___________________ |Arthritis |
|_____________________________________________________________ |Asthma |
| |Cancer |
|How many hours per day do you spend on digital devices? ______________ |Heart disease |
| |High cholesterol |
| |HIV |
|Please list all medications that you are taking at this time (including pills, creams, drops, |Hypertension (high blood pressure) |
|oral contraceptives, aspirin, over-the-counter medications, birth control and home remedies): |Migraines/headaches |
|[pic] |Multiple sclerosis (MS) |
| |Regular Headaches |
| |Diabetes |
|Allergies: |If so, |
|[pic] |Type 1 / Type 2 |
| |How long have you had it? __________ |
| |A1C?____________________________ |
|Do you use tobacco? Never / Past / Current |Other: |
|If current, what type and how often? ________________ |[pic] |
| | |
|Do you consume alcohol? Yes / No | |
|If yes, how often? ________________ | |
| | |
|Are you pregnant? Yes / No | |
|Family History (please check all that apply) | |
| None | Cataracts | Diabetes |
|Glaucoma |Lazy Eye |High Cholesterol |
|Macular Degeneration |High Blood Pressure |Multiple Sclerosis (MS) |
|Retinal Detachment |Heart Disease | |
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