"FOR THE ONLY EYES YOU'LL EVER HAVE"

New Patients

If you are a new patient - please print off the forms below and bring them in at your appointment OR you can fill them out online and submit them online.  If you have any questions please Contact Us.

 

 

Patient Basic Information
Patient Medical Information

 

 

Patient Information

Name: Sex:
F   M  
Address: Marital Status:
S   W D M
City: State:
Zip: Date of Birth:
SS#: Co-Pay:
Age: Race:
Home Phone: Work Phone:
Cell Phone: E-mail:

 

Insurance

Primary: Contact#:

Group

(If available):

Policy Holder

Policy Holder DOB:    
Secondary: Contract #:

Group

(If available):

Policy Holder

Policy Holder DOB:    

 

Responsible Party

Name: Phone
Relation:    

 

Person to notify in Case of Emergency

Name: SS#:
Address: City/State/Zip:
Phone: Referring Source:
1.  List any family members that are patients here:
2. Nature of problem(s):

3. Employed by:

 

AUTHORIZATION TO RELEASE INFORMATION:  I authorize INSTITUTE FOR TOTAL EYE CARE, P.C., to release any medical information necessary to process health insurance claims.  I also authorize payment directly to the physician of the surgical and/or medical benefits, if any, otherwise payable to me for this service as described.  ACKNOWLEDGEMENT OF RESPONSIBILITY:  I understand that I am financially responsible to you for all professional services rendered, including but not limited to those services which are not covered by Blue Shield PMD/Medicare programs or other private and commercial insurance programs (co-payments, refractions, and/or deductibles).  I also understand that if I have an HMO insurance and do not obtain the proper referral number prior to my visit, that I am financially responsible for any charges incurred.  I understand that payments for these charges are due at the time of service.  In the event of default, I agree to pay all collection costs, including a reasonable attorney fee.  Also, I acknowledge receipt of ITEC's "Notice of Privacy Practices" and further authorize ITEC, its employees and or agents, to contact me at any/all phone numbers, including my cell phone I have provided and to discuss with any family members or care givers anything about my private health information insurance and payments.

 

Patient/Parent/Guardian SIGNED

Date: 

 

 

NAME:
CHART#: ____________________________ (OFFICE)
DATE: _______________________________(OFFICE)
MEDICAL DR.: _________________________(OFFICE)

 

 

 

 

 

 

 

REVIEW OF SYSTEMS / PAST MEDICAL HISTORY:

*Medications must be listed

 

      Do you now have/had problems with any of the following.

      If "YES", Please explain:

Eyes NO YES
Ears, Nose, Throat NO YES
Heart, Blood, Vessels, HBP NO YES
Lungs/Breathing NO YES
Stomach, Intestines, Liver NO YES
Kidneys, Bladder, Genital NO YES
Muscles, Joints NO YES
Skin/Breast NO YES
Brain Spinal Cord, Nerves NO YES
Psychiatric NO YES
Diabetes, Thyroid NO YES
Blood Problems, Swelling NO YES
Allergies, Immune NO YES
OTHER NO YES

 

Past Surgical History:
Previous Eye Problems or Surgeries:

 

Are you currently wearing:
Glasses? Soft Contacts? Hard Contacts?
Are you interested in soft contacts?
Soft Contacts? Hard Contacts?
Are you interested in refractive surgery?
Medications you are taking:
Drug Allergies:
Social History:
Marital Status: M          S         W D
Smoker:  No  Yes
Drink Alcohol:  NO  Yes
Current Occupation

 

Family History - Eyes:

Glaucoma  NO  YES
Cataracts:  NO  YES
Muscular Degeneration  NO  YES
OTHER  NO  YES

 

Family History - General Health:

Heart Disease:  NO  YES
High Blood Pressure:  NO  YES
Diabetes:  NO  YES
Cancer:  NO  YES
OTHER:  NO  YES