Lee Eyecare Center
LEE EYECARE CENTER
9265 E Baseline Rd Ste 102 Christopher E. Lee, OD
Mesa, AZ 85209 Linh H Dao, OD
(480) 354-4030
Fax (480) 954-4492
PATIENT INFORMATION
|Last Name First Name M.I. Sex |
|Date of Birth Age |
|Address City State Zip Code |
|Home Phone Cell Phone |
|Email Address: |
|Name of Member Insured Insured’s ID/SSN |Insurance Company |
|Group # / Policy# |Employer’s Name |
| FINANCIAL ACKNOWLEDGEMENT |
| |
|I hereby authorize any person/institution rendering care to furnish all fact concerning this claim. I authorize payment for my vision benefits to go directly to Lee |
|Eyecare Center. I agree that if my employer, insurance carrier or plan sponsor denies payment to all or any portion of my claim, I will be financially responsible for |
|all outstanding charges. Authorization obtained at time of service does not guarantee payment. |
|Signature Date of Service |
|Relationship to Insured |
|( Self ( Spouse ( Child ( Other |
PATIENT HISTORY
What is the reason for today’s exam? ( General Check-up ( Eye infection/injury
( Want new glasses ( Want new contact lenses
When was your last exam? _____________________________ How old are your present glasses? ____________________
When do you use your glasses or contact lenses? ( Constantly ( Reading Only ( Distance Only
Please Check If The Following Applies To You:
Current Eye Condition Eye Health History
( Light Sensitivity ( Intermittent Loss of Vision ( Flashes or light or
( Blurred Distance with present ( glasses or ( contacts ( Eye Injury ( Floaters
( Blurred Near vision with present ( glasses or ( contact ( Severe Head Injury ( Eye surgeries
( Blurred near vision without ( glasses ( contacts ( Eye Infection ( Retinal Disease
( Headaches ( Double Vision ( Halos or Rainbows near lights ( Cataracts
( Uncomfortable vision or tired eyes ( Distorted Vision ( Crossed/ Wandering/ Lazy Eye
( Dry Eyes ( Usu. Red or irritated eyes ( Glaucoma
General Health Condition Family History
( Heart Disease ( Pregnant, how many months? _________ ( Cataracts
( Diabetes ( Glaucoma
( High Blood Pressure ( Retinal Disease / Retinal Detachment
( HIV ( Macular Degeneration
( Allergies ( Crossed/Wandering/Lazy Eye
( Cancer ( Diabetes
( Thyroid Problems ( High Blood Pressure
( Allergic to Medications: ___________________________________ ( Any Inherited Disease? ____________
( Current Medications ______________________________________
Contact Lenses History
• Do you wear Contact Lenses? (No (Yes, Days per Week:_________________ Last Worn Routinely: _____________________
• Type of contacts last worn: Soft Disposables Gas Perm Manumission Astigmatism/Toric
• Method of wear: Daily Wear Extended Wear Flexible/Part Time Wear
• Name Brand of your contacts:__________________________________________
• What Lens Care System do you use? Renu Optifree Complete ClearCare Boston Other/Generic_______________
• Have you ever had an eye health problem related to contacts? No Yes, Please explain_________________________________
• How old are your current Contact Lenses? _______________
• How often do you replace you disposable Contacts Lenses? Daily 2-3 weeks Monthly Yearly
• If you are an extended wearer, how many nights per week do you sleep with them on? ___________________
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