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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