Name(Required)

First Middle Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Mobile Phone(Required)

Email(Required)

Sex

Marital Status:(Required)

Single

Married

Divorced

Widowed

Social Security(Required)

Date of Birth(Required)

Primary Care Dr(Required)

Preferred Pharmacy(Required)

Phone Nbr(Required)

Pharmacy Phone(Required)

Emergency Contact(Required)

First Last

Phone Nbr(Required)

Is the patient is under the age of 18?(Required)

Yes

Who is responsible for the patient?(Required)

Name

First Middle Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Social Security(Required)

Primary Medical Insurance(Required)

ID(Required)

Subscriber(Required)

First Middle Last

Date of Birth(Required)

Sec. Medical Insurance

Subscriber

First Middle Last

Date of Birth

Vision Insurance

Due to new regulations mandated at both the state and federal level, we are now obligated to collect the race, ethnic background and preferred language of each patient. This information will go into your medical record and remains strictly confidential.

Please chose your race(Required)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Other Race or Multiple Races

White

Please chose your ethnic background(Required)

Hispanic or Latino

Non Hispanic or Latino

What is your preferred language(Required)

Please chose how would you prefer to be notified/reminded about future appointments, optical orders and contact lens orders?(Required)

Text message

Call my mobile number

Call my work number

Call my home number

Email only

I hereby consent to a health examination, related diagnostic procedures and treatments provided by the Eye Center. I hereby authorize my insurance company(s) to remit directly to the Eye Center all payment of benefits otherwise payable to me under the provision of my policy(s). I request that payment of authorized Medicare/Medicaid benefits be made either to me or on my behalf to the Eye Center for any services provided to me. I hereby authorize the release of this information needed to determine benefits payable for related services. I also authorize the use of any photographs or data collections taken to document my ocular condition for routine care or use in research and professional publication. Photo static copies of this authorization will be considered valid as the original.

If my insurance company requires referrals, vouchers or authorizations, I will present these to the receptionist immediately. Failure to do so will make me responsible for full payment once services are rendered.

Signature(Required)

Please chose one(Required)

Patient

Parent

Legal Guardian

Responsible Party

I have received a copy of the "Notice of Privacy Practices"(Required)

initial

GENERAL HISTORY

Name(Required)

First Last

DOB(Required)

Sex:

Male

Female

1.Allergies:

2.Have you had a flu shot this season?(Required)

Yes

3.If you are over the age of 65, have you had a pneumonia shot?(Required)

Yes

4. History of the following diseases: (please check all that apply)

Cardiac

1. Heart disease

2. High blood pressure

Respiratory

1. Asthma

2. Bronchitis

3. Emphysema

4. Oxygen dependence COPD

Neurological

1. Stroke

2. Seizures

Kidney

1. Renal insufficiency/failure

2. Dialysis dependence

Endocrine

1. Diabetes

Type

2. Thyroid Problems

Musculoskeletal

1. Walker/wheelchair use

2. Joint pain

Location:

3. Rheumatoid Arthritis

Gastrointestinal

1. Gastro-esophageal reflux

2. Hiatal hernia

Eye Disease

1. Cataracts

2. Glaucoma

3. Macular degeneration

4. Retinal detachment

Ear/Nose/Throat

1. Chronic cough

2. Hearing aid use

Psychiatric

1. Depression

2. Anxiety

Other

1. Cancer

Type:

2. Cholesterol

3. Lupus

4. Bleeding disorders

Type:

5. HIV

6. Hepatitis

Type:

Else

Who?

5. Current medications:(Required)

6. Previous surgeries:(Required)

7. Do you smoke?(Required)

Yes

Quantity:

Do you use smokeless tobacco?(Required)

Yes

Quantity:

how long ago?

8. Alcohol consumption?(Required)

Yes

Quantity:

9. Drug abuse?(Required)

Yes

Type:(Required)

10. If you are female, possibility of pregnancy or breastfeeding?(Required)

Yes

11. Do you have an Advanced Directive for Healthcare (Living Will) _(Required)

Yes

12. Do you suffer from any of the following?

13. Do you wear glasses?(Required)

Yes

Do you wear contact lenses?(Required)

Yes

Hard

Soft

Brand:(Required)

Power:(Required)

Right

Left

How many hours per day?(Required)

Authorization of Use and Disclosure of Protected Health Information for Individuals

Persons Authorized to Receive Information:
Health information Optomedica Eye Consultants, LLC collects or received about you may be disclosed to the following persons:

Name of person

First Last

Relation

Name of person

First Last

Relation

Use and Disclosure of Information:
I authorize the person(s) listed above to receive all health information about appointments, treatment and/or other information pertinent to my healthcare and/or payment for my health care provided at Optomedica Eye Consultants, LLC .

Expiration Date of Authorization This authorization is effective through

Date(Required)

unless revoked or terminated by the patient or patient’s personal representative.

Right to Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to Optomedica Eye Consultants, LLC/Caplan Surgery Center. You should contact our Privacy Officer to terminate this authorization.

Potential to Re-disclosure
The person to whom health information is sent may repeatedly disclose health information that is identified by this authorization. The privacy of this information may not be protected under the federal privacy regulations

Signature of Patient(Required)

Date(Required)

Name of Patient (Print or Type)(Required)

First Last

Signature of Patient Representative(Required)

Relationship to Patient(Required)