Eye Care Experts You Can Trust | Vision Pro Optical



[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 | |

-----------------------

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download