DR. WILLIAM T. DOTY & DR. PATRICK M. DOTY



WELCOME TO THE OFFICE OF DR. WILLIAM DOTY and DR. PATRICK DOTY Name: _______________________________________ Nickname: ________________ Date of Birth: ____ /_____ /_____Address: _____________________________________ City: ___________________ State: _____ Zip: _______________Primary Phone: ______________________ cell __Y __N Alternate Phone: ______________________ cell __Y __ NE-mail Address: ____________________________________________ Preferred Contact (circle one): Phone Email Text Social Security #: ______________________________ Gender: __Male __Female Height: _____ Weight: ______Marital Status: __Married __Single __Divorced __Legally Separated __Widowed Employment Status: __FT __PT __Self Employed __FT Student __ PT Student __Retired __Not EmployedEmployer: ________________________________________________________________________________________ Primary Care Physician: ______________________________ Referred to us by: ____________________________Pharmacy: ________________________ Location (street & city):__________________________________________Race (check one): ___ American Indian ___Asian ___Black or African American ___White ___Unspecified Ethnicity (check one): ___ Hispanic ___ Not Hispanic ___Native Hawaiian or other Pacific Islander Preferred Language (check one): ___English ___French ___Spanish ___Japanese ___Portuguese Guarantor/Responsible Party: ________________________________________ Date of Birth:_________________Address: __________________________________ City: __________________ State: _____ Zip: __________ Home Phone: _______________________ Email Address: ___________________________________Cell Phone: _________________________ Relationship to Patient: ____________________________Insurance InformationMedical Provider Name: ____________________________ Member ID#: ____________________________Primary insured: __ Self __OtherIf Other, Name of insured: _________________________________ DOB: _____________________Relationship to the insured: __ Spouse __ Child __OtherVision Provider (if any): ______________________________ Member ID#: ___________________________Primary insured: __ Self __OtherIf Other, Name of insured: __________________________________ DOB: ______________________Relationship to the insured: __ Spouse __ Child __OtherPlease continue on the back side of this page AllergiesAllergen______________________________ Reaction: __________________________________ __Mild __Moderate __SevereAllergen_________________________________ Reaction: _______________________________ __Mild __Moderate __SeverePast Ocular History (Please mark all that apply)__Overall Healthy__Cataracts __Hyperopia __Myopia__Amblyopia (lazy eye) __Diabetic Retinopathy __Iritis__Optic Neuritis__Aphakia__Dry Eyes__Keratoconus __Retinal Detachment__Astigmatism __Glaucoma__Macular DegenerationOther: _________________________________________________________________________________________________________Ocular Surgeries (Please mark all that apply)__No Prior Ocular Surgery __Foreign Body Removal __Punctal Plugs __LASIK__Blepharoplasty __Retinal Laser Surgery __RK__Vitrectomy __Cataract Surgery__Strabismus Surgery__PRK (eye muscle surgery)__Corneal Transplant__Trabeculectomy (Glaucoma Surgery)Other: _______________________________________________________________________________________________Ocular Significant Illnesses (Please mark all that apply)__Overall Healthy__Herpes __Hypothyroidism__Sjogrens__AIDS __HIV Positive __Lupus __Graves Disease__Diabetes__Hypertension __Multiple Sclerosis__Hyperthyroidism__Rheumatoid ArthritisOther: _______________________________________________________________________________________________Current Eye Medications (Please list all):_________________________________________________________________Systemic Illnesses (Please mark all that apply):__No History of illness __Congestive Heart Failure __Hepatitis__Lung Disease__Anemia__COPD __High blood pressure __Lupus__Arthritis__Diabetes__High Cholesterol__Migraine__Arrhythmia__Eczema__HIV__Polymyalgia__Asthma__Fibromyalgia __Kidney disease __Psychiatric Disorder__Bleeding Disorder__Headache__Kidney Stones __Skin Cancer__Cancer__Hearing loss __Liver Disease __Stroke__Thyroid Disease Other: ________________________________________________________________________________________________General Surgeries/Operations (Please list all):_____________________________________________________________________________________________________________________________________________________________________Other Current Medications: (Please list all):_______________________________________________________________________________________________________________________________________________________________________Infections (Please mark all that apply):__Overall Healthy__Herpes Simplex__HIV/AIDS__Syphilis__Chicken Pox __Herpes Zoster/Shingles __Meningitis__Toxoplasmosis__Hepatitis A/ B/ C __Histoplasmosis __MRSA __Wound Infection Other: _______________________________________________________________________________________________________Family History for First Degree Relatives (parent, child, sibling)__Arthritis__Diabetes__Kidney Disease__Stroke__Blindness__Glaucoma__Lazy Eye__TB__Cancer__Heart Disease __Macular Degeneration__Cataracts__High Blood Pressure __Retinal Disease Other: ______________________________________________________________________________________________Social History (Please mark all that apply)Smoking: __Current every day smoker __Current some day smoker __Former smoker __Never smoked Alcohol Use: __Yes __No If yes, what and how often? ___________________________________Drug Use: __ Yes __No If yes, what and how often? ___________________________________Review of Systems (Please mark all that apply)EyesRespiratoryBlood/Lymphatic_Previous Surgery_Cough _Easy bruising_Contact Lens_Congestion_Gums bleeding easy_Pain_Wheezing_Prolonged bleeding_Double Vision _Asthma_Heavy aspirin use_Glaucoma_CataractsGastrointestinal Musculoskeletal_Macular Degeneration _Heartburn_Stiffness_Dry Eyes _Nausea/Vomiting_Arthritis_Flashes _Jaundice/Hepatitis_Joint pain/Swelling_FloatersGenitourinary SkinEar, Nose, and Throat _Pain/Difficulty _Rash/Sores_Hard of hearing _Blood in urine _Lesions_Ringing in ears _History of kidney stones _Hives/Eczema_Vertigo _History of STD’s NeurologicalCardiovascular Psychiatric_Seizures_Chest Pain_Anxiety/Depression_Weakness/Paralysis_Dizziness_Mood swings_Numbness_Fainting spells _Difficulty sleeping_Tremors_Shortness of breathe _Irregular heart beatEndocrineImmunologic_Difficulty lying flat_Increased thirst _Hives_Increased hunger_ItchingConstitutional _Increased sweating_Runny Nose_Fatigue/Weakness_Fingernail changes_Sinus Pressure_Fever_Weight gain/LossINSURANCE COVERAGE OR PRIOR AUTHORIZATION WAIVERIf you do not have your insurance card today:I understand that since I do not have my current insurance card, my exact coverage cannot be verified. I also understand that if my insurance is a referral plan, or if my plan requires prior authorization, I will be held responsible for today’s bill.If you have not received prior authorization:I understand that under my insurance plan, a referral from my primary care physician may be necessary prior to seeing Dr. Doty. Since the referral or prior authorization could not be verified today, I understand that I may be held responsible for payment.Today’s visit is for: (check one)__ Exam related to vision, glasses or contacts__ Medical, state reasons: __________________________________________________Signed: ___________________________________________ Date: ____________________I have read or received a copy of Dr. William T. Doty’s notice of Privacy Practice.Signed: ________________________________________________ Date: ____________________Please Note: Insurance may cover only part of your charges. If we do not accept direct payment from your insurance plan, you will need to pay our office and submit your receipt for reimbursement from your insurance company. If your insurance does not pay as directed, you are ultimately responsible for all charges. We cannot be responsible if you are not eligible for benefits. ................
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