INSURANCE INFORMATION:

( ) MEDICARE#____________________ ( ) MEDICARE SUPPLEMENT NAME_______________________#______________

( ) MEDICAID#____________________ ( ) VSP # _____________________________ (This is the primary insured social security #)

                                                                              VSP requires a full VSP ID # to file your claim

FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT:

I understand and agree that (regardless of my insurance status) I am ultimately responsible to pay all fee and charges for

treatment of the person named above.  I agree to pay all charges for me and all members of my family  when services are

rendered.  A Finance charge of 2% per month will be added to all billing not paid when services are rendered.  In the event

to, reasonable attorney's fee and court costs.  I agree that payment will not be delayed or withheld because of my insurance or

 the pending of claims thereon, and all  proceeds of insurance are assigned to this office unless otherwise paid, but without

assuming any responsibility for the collection thereof. (A copy of this assignment is as valid as th original.

 

Signature:_______________________________________________________________________

 

Today’s Date:_____________________                                               Doctor’s Initials (reviewed both pages)________

*Please turn this form over and complete side two*

 

 

 

 

 

 

Social History      This information is kept strictly confidential.  However, you may discuss this portion with the doctor if you prefer.

                                       ___Yes, I would prefer to discuss my Social History information directly with my doctor, (Check Box)

Do you drive?  ___Yes  ___No   If yes, do you have visual difficulty when driving?  ___Yes ___No  If yes, please describe:

             _____________________________________________________________________________________________________

Do you use tobacco products?             ___Yes  ___No            If you, type / amount / how long:_________________________________

Have you ever been exposed to or infected with:        ___Gonorrhea               ___Hepatitis                  ___HIV            ___Syphilis

 

Review of Systems

Do you have any problems in the following areas:

 

 

 

 

                                                                                                                                                                                                                       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTEM

NEUROLOGICAL

Headaches

Migraines        

Seizures

EYES

Loss of Vision

Blurred Vision

Distorted VisionHalos

Loss of Side Vision

Double Vision 

Dryness

Mucous Discharge

Redness

Sandy or Gritty Feeling

Itching

Foreign Body Sensation

Excess Tearing/Watering

Glare/Light Sensitivity

Eye Pain or Soreness

Chronic Infection of Eye

Sties or Chalazion

Flashes or Floaters

Tired Eyes

 

EARS, NOSE, MOUTH, & THROAT

Allergies / Hay Fever

Sinus Congestion

Runny Nose

Post Nasel Drip

Chronic Cough

Dry Throat/Mouth

RESPIRATORY

Asthma

Chronic Bronchitis

Emphysema

VASCULAR/CARDIOVASCULAR

Diabetes

Heart Pain

High Blood Pressure

Vascular Disease

GASTROINTESTINAL

Diarrhea

Constipation

LYMPHATIC/HEMATOLOGIC

Anemia

Bleeding Problems

ENDOCRINE

Thyroid/Other Glands

 

O

O

O

 

O

O

O

O 

O

O

O

O

O

O

O

O

O

O

O

O

O 

O

 

NO

YES

??

NO

YES

??

 

O

O

O

O

O

O

 

O

O

O

 

O

O

O

O

 

O

O

 

O

O

 

O

 

 

O

O

O

O

O

O

 

O

O

O

 

O

O

O

O

 

O

O

 

O

O

 

O

 

 

O

O

O

O

O

O

 

O

O

O

 

O

O

O

O

 

O

O

 

O

O

 

O

 

 

O

O

O

 

O

O

O

O 

O

O

O

O

O

O

O

O

O

O

O

O

O 

O

 

 

O

O

O

 

O

O

O

O 

O

O

O

O

O

O

O

O

O

O

O

O

O 

O

 

Eye Disease                               

Eye Injury                                 

Eye Surgery                              

Heart Disease                            

High Blood Pressure                

Glaucoma                                               

Macular Degeneration

Thyroid Disease                   

 

                       

Allergies                                   

Asthma                                     

Arthritis                                    

Cancer                                      

Cataracts                                  

Diabetes                                   

Eye Disease                          

Text Box: Medical History Questionaire PLEASE COMPLETE ALL INFORMATION Name:_____________________________________________PREFERRED NAME:____________________________ ( ) Male ( ) Female ( ) Child ( ) Single ( ) Married ( ) Divorced ( )Widowed Mailing Address:__________________________________________________________________________________ City & State:______________________________Zip:______________Home Phone:___________________________ Your Employer:__________________________________________________Work Phone:_____________________ Birth Date:_____/_____/_____Patient’s Social Security #:________/_________/________Last Eye Exam:_________ Parent (if minor) or Spouse’s Name:___________________________________________________________________ Parent (if minor) or Spouses Employer & Phone #:_______________________________________________________ Email:_____________________________________________________________________________ NEAREST RELATIVE NOT LIVING WITH YOU:_______________________________________________________________ (Name, Address & Phone Number) Name of Medical Doctor:_____________________________________________________________________________________ Medical History Do you have any allergies to medication? ___yes ___no Do you have allergies to anything else?:___________________________ __________________________________________________________________________________________________________ List any medications you take (including oral contraceptives, aspirin, over the counter medications): __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, Cataracts, eye infections, or eye injury:____________________________________________________________________ Do you wear glasses? __yes __no If yes, how old is your present pair of lenses?___________________________ Do you wear contact lenses? __yes __no If yes, how old is your present pair of lenses?___________________________ Type of contact lenses: __Rigid __Soft __Extended Wear __Other Are they comfortable? __yes __no FOR FEMALE PATIENTS: Are you pregnant and/or nursing? ___yes ___no

PERSONAL & FAMILY MEDICAL HISTORY

                      (Please heck those that apply)

If you answered YES to any of the above or have a condition not listed, please explain & list medications:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

HIPPA Privacy Acknowledgement of Receipt of Notice of Privacy Practice:

I, _____________________________________[Please print full legal name here], have been presented with the Notice of

Privacy Policy (the “Policy”) of Eyecare Associates of Wyoming, and have been offered a copy to keep for my records.

Signature____________________________________________________________Date___________________________

Method of Payment:  ( ) Cash/Check      ( ) Visa/Mastercard

ALL PAYMENTS ARE DUE AN THE DATE OF SERVICE

___self___family                     

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___self___family
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