Patient-Forms Name(Required) First Middle Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneMobile Phone(Required)Email(Required) Sex M F Marital Status:(Required) Single Married Divorced Widowed Social Security(Required)Date of Birth(Required) MM slash DD slash YYYY 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 No 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) MM slash DD slash YYYY Sec. Medical Insurance ID Subscriber First Middle Last Date of Birth MM slash DD slash YYYY Vision Insurance ID 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)initialGENERAL HISTORYName(Required) First Last DOB(Required) MM slash DD slash YYYY Sex: Male Female 1.Allergies: 2.Have you had a flu shot this season?(Required) Yes No 3.If you are over the age of 65, have you had a pneumonia shot?(Required) Yes No 4. History of the following diseases: (please check all that apply)Cardiac1. Heart disease Self Mother Father Grandmother Grandfather Sibling Child Other 2. High blood pressure Self Mother Father Grandmother Grandfather Sibling Child Other Respiratory1. Asthma Self Mother Father Grandmother Grandfather Sibling Child Other 2. Bronchitis Self Mother Father Grandmother Grandfather Sibling Child Other 3. Emphysema Self Mother Father Grandmother Grandfather Sibling Child Other 4. Oxygen dependence COPD Self Mother Father Grandmother Grandfather Sibling Child Other Neurological1. Stroke Self Mother Father Grandmother Grandfather Sibling Child Other 2. Seizures Self Mother Father Grandmother Grandfather Sibling Child Other Kidney1. Renal insufficiency/failure Self Mother Father Grandmother Grandfather Sibling Child Other 2. Dialysis dependence Self Mother Father Grandmother Grandfather Sibling Child Other Endocrine1. Diabetes Self Mother Father Grandmother Grandfather Sibling Child Other Type 2. Thyroid Problems Self Mother Father Grandmother Grandfather Sibling Child Other Musculoskeletal1. Walker/wheelchair use Self Mother Father Grandmother Grandfather Sibling Child Other 2. Joint pain Self Mother Father Grandmother Grandfather Sibling Child Other Location: 3. Rheumatoid Arthritis Self Mother Father Grandmother Grandfather Sibling Child Other Gastrointestinal1. Gastro-esophageal reflux Self Mother Father Grandmother Grandfather Sibling Child Other 2. Hiatal hernia Self Mother Father Grandmother Grandfather Sibling Child Other Eye Disease1. Cataracts Self Mother Father Grandmother Grandfather Sibling Child Other 2. Glaucoma Self Mother Father Grandmother Grandfather Sibling Child Other 3. Macular degeneration Self Mother Father Grandmother Grandfather Sibling Child Other 4. Retinal detachment Self Mother Father Grandmother Grandfather Sibling Child Other Ear/Nose/Throat1. Chronic cough Self Mother Father Grandmother Grandfather Sibling Child Other 2. Hearing aid use Self Mother Father Grandmother Grandfather Sibling Child Other Psychiatric1. Depression Self Mother Father Grandmother Grandfather Sibling Child Other 2. Anxiety Self Mother Father Grandmother Grandfather Sibling Child Other Other1. Cancer Self Mother Father Grandmother Grandfather Sibling Child Other Type: 2. Cholesterol Self Mother Father Grandmother Grandfather Sibling Child Other 3. Lupus Self Mother Father Grandmother Grandfather Sibling Child Other 4. Bleeding disorders Self Mother Father Grandmother Grandfather Sibling Child Other Type: 5. HIV Self Mother Father Grandmother Grandfather Sibling Child Other 6. Hepatitis Self Mother Father Grandmother Grandfather Sibling Child Other Type: Else Who?Self.MotherFatherGrandmotherGrandfatherSiblingChild5. Current medications:(Required)6. Previous surgeries:(Required) 7. Do you smoke?(Required) Yes No Quantity:Do you use smokeless tobacco?(Required) Yes No Quantity:how long ago? 8. Alcohol consumption?(Required) Yes No Quantity:9. Drug abuse?(Required) Yes No Type:(Required) 10. If you are female, possibility of pregnancy or breastfeeding?(Required) Yes No 11. Do you have an Advanced Directive for Healthcare (Living Will) _(Required) Yes No 12. Do you suffer from any of the following? Blurry vision Sinus problems Watery eyes Pain in your eyes Dizziness Floaters Dry eyes Seasonal allergies Headaches Flashes of light Halos Other (Required) 13. Do you wear glasses?(Required) Yes No Do you wear contact lenses?(Required) Yes No (Required) Hard Soft Brand:(Required) Power:(Required) Right Left How many hours per day?(Required) Authorization of Use and Disclosure of Protected Health Information for IndividualsPersons 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 throughDate(Required) MM slash DD slash YYYY 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) MM slash DD slash YYYY Name of Patient (Print or Type)(Required) First Last Signature of Patient Representative(Required)Relationship to Patient(Required)