PRIME EYE CARE



Patient Name: __________________________________________________ DOB_________________________SSN # __________________________ Sex _____M_____F Marital Status _____M_____S_____WAddress:__________________________________ City:________________ State: _________Zip:________Phone: Home __________________ Cell ________________________ Can we text you? Yes ____ No ____Email Address: __________________________________________________________________________Primary Care Physician ____________________________ ____Phone Number_______________________Last Eye Doctor__________________________________ Last Eye Exam ____________________________Primary Insurance:Medical__________________________ Member ID# _________________ Group#___________________Vision ___________________________ Member ID# _________________ Group#___________________Secondary Insurance:Medical__________________________ Member ID#__________________ Group#___________________Policy Holder:Name:________________________________DOB:________________SSN#_________________________Ocular HistoryPlease circle any disease or surgeries that you have been treated for in the past.CataractsMacular DegenerationGlaucomaRetinal DetachmentIritis/UveitisOcular Surgeries:Cataracts / Retinal / Glaucoma / Muscle / Lid / Cornea / RefractiveOcular Medications: ____________________________________________________________________________Ocular Injuries: ________________________________________________________________________________Family HistoryPlease circle any health problems that any immediate family member has.Diabetes / High Blood Pressure / Heart / Lung / Stroke / Cancer / Glaucoma / Macular DegenerationSocial HistoryDo you smoke or chew tobacco?YES / NOHow many cigarettes per day? ____________Do you drink alcohol?YES / NOHow much per day? _____________________Do you use any illicit drugs?YES / NOMedicationsPlease list ALL medications you are presently takingAre you allergic to any medications? Please listHow did you find out about our office?Insurance / Friend or Family / Expo / Doctor Referral / Advertisement / Previous PatientOccupation _______________________________________________________________________Authorized Individual to discuss your eye health with: __________________________________________________PLEASE COMPLETE THE BACK SIDE OF THIS FORMMedical HistoryDo you currently, or have you ever had any problems in the following areas:YESYESCONSTITUTIONALEAR / NOSE / THROATFever, Weight Loss / Gain___Tinnitus___CARDIOVASCULAREar Infection___Hypertension___Allergies___Heart Attack (MI)___RESPIRATORYCholesterol___Emphysema___Congestive Heart Failure___Bronchitis___Coronary Artery Disease___Asthma___Aneurysms___COPDArrhythmias___Lung Cancer___GASTROINTESTINALPneumonia___Ulcers___MUSCULOSKELETALBowel Disorders___Arthritis___Reflux Disease___Osteoporosis___Diverticulitis___Gout___Colon Cancer___TMJ___INTEGUMENTARYENDOCORINESkin Cancer___Diabetes___Psoriasis___Thyroid___Rosacea___Pituitary___NEUROLOGICALHEMATOLOGIC / LYMPHATICMultiple Sclerosis___Anemia___Alzheimer’s___Leukemia___Stroke___Lymphoma___Parkinson’s___Breast Cancer ___Headaches___GENITOURINARY___Muscular Dystrophy___Renal Failure___IMMUNOLOGYUrinary Tract Infection___HIV___Sexually Transmitted Disease___AIDS___Nephritis___PHYCHIATRICProstate Cancer ___Depression___Ovarian CancerDrug Dependence___OTHER PLEASE LISTEating Disorder___Alcoholism___Schizophrenia___Panic Disorder___I authorize and request that payments under my insurance plan be made directly to Prime Eye Care for the services furnished to me. I also authorize Prime Eye Care to release information needed for treatment, payment of claims and healthcare operations. I further permit copies of this authorization to be used in place of the original. I do realize that there will be a portion of the bill that is my responsibility and do agree to pay that portion. I understand and agree, should my account be turned over to a collection agency, I will be responsible for collection fees of 50% of the outstanding balance. I also understand and agree that should a suit be brought against me I will pay court costs and attorney fees.Patient Signature: ________________________________________________ Date: __________________________ ................
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