Patient History Form

Name*

First Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HOME PHONE

WORK PHONE

CELL PHONE*

E-MAIL ADDRESS*

I attest that I have not had any symptoms or any exposure to anyone who has COVID- 19. I also accept the risk and consent to a visit today

Signature

Occupation

Employer

Family Doctor

Are you pregnant/nursing

Yes
No

What brought you in today

Are you interested in

Personal Eye History: Check all that apply

Review of Systems

check all that apply or check None

General Health*

Ear/Nose/Throat*

Cardiovascular*

Respiratory*

Gastrointestinal*

Gastro-urinary*

Muscle/Skeleton*

Integumentary*

Neurological*

Psychological

Endocrine*

Lymphatic/Blood*

Allergies/Immune*

Do you currently take any medications? Please list and indicate dosage and frequency if known

None

Do you have any allergies to medications? Please list with reactions

None

Do you use OR have you ever used the following products

Tobacco*

Yes
No
Previous

if yes indicate frequency/past use

Alcohol*

Yes
No
Previous

if yes indicate frequency/past use

Other Drugs*

Yes
No
Previous

if yes indicate frequency/past use

Family History (If yes, please indicate who in the family)

Macular Degeneration

Glaucoma

Cataracts

Cancer

High Blood Pressure

Diabetes

Thyroid

Condition

Cholesterol

NONE

Please list any other condition you would like us to know about

How you were referred to us

Insurance Information

Insurance Provider*

Insurance ID Number*

Group Number*

Guarantor information required if under the age of 18

Please list who will be the guarantor for this account if patient is under the age of 18

Name	Cell Phone	Address (if different from patient)

Dilation

I Authorize my child's eyes to be dilated
I decline to have my child eyes dilated

Contact Lens Evaluation

Contact lens evaluations are $58-$128 depending on your prescription and the type of contact lens used to meet your needs.

YES, I would like to update my CL prescription prescription at this time
NO, I do not need a CL

The contact lens evaluation includes trial contact lenses, any neccessary follow up visits, as well as training needed to help insert and remove your contact lenses.

If you are a current contact lens wearer, a new evaluation is performed each time you are seen by a doctor.

Acknowledgement of Receipt of this Notice

This Practice is concerned about the privacy of our patient’s health care information. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your healthcare services will in no way be conditioned upon your signed acknowledgement. If you decline to provide a signed acknowledgement, we will continue to provide your treatment and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.

I acknowledge that I have received the Notice of Privacy Practices for Vision Plus.

Signature of patient/authorized representative

Hidden

Date

Patient History Form

Review of Systems

Do you use OR have you ever used the following products

Family History (If yes, please indicate who in the family)

Insurance Information

Guarantor information required if under the age of 18

Contact Lens Evaluation

Acknowledgement of Receipt of this Notice

Section Break

Stanwood Office

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