lapalmaeye.com - New Patient Form

New Patient Form

Information gathered is for insurance and communication purposes only. It will never be shared or sold.
Name*

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Birth Date

MonthDayYear
Date
Marital Status

MarriedSingle
Sex

MF
SS#
Address

Street Address

Street Address Line 2

CityState

Zip Code
Responsible Party

SelfOther
Other
Relationship
Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
HEALTH PLANS:

We are an in-network provider for literally dozens of health and vision insurance plans. Even though we provide complimentary insurance billing it is your primary responsibility to learn about your plans' coverage. Ultimately you are responsible for your out-of-pocket expenses based on the deductible, co-insurance and copays of your medical insurance or vision plan.
Primary Insurance
ID#
GRP#
PPOHMOMedi-CalMedicare
Secondary Insurance
ID#
GRP#
PPOHMOMedi-CalMedicare
Vision Plan

VSPEyemedSpecteraDavisMES
Subscriber Name

Self
Emergency contact
Name
Phone Number

Area CodePhone Number
Name of family physician
I authorize payment of medical or vision benefits and release of medical information to Ilan Hartstein, M.D inc.. I agree to pay any amount approved but not paid for by my insurance eg: deductible, co-insurance, copay or non covered services. I acknowledge that I have received a copy of the notice of Privacy Practice.
Signature
Date

MonthDayYear
Date
Comprehensive History
Referred by

DoctorFriendFamily Member
What is your chief complaint / reason for visit?
Previous Eye History

None
Previous Medical History

None
Allergies to medications

YesNo
If yes, please list allergies:
Current medications or drops

None
Medical History / System Review
Do you have or have you had any of these conditions? Please check only those that apply

AsthmaStrokeThyroidCholesterolHigh Blood PressureDiabetesCancerNone of the above
Family History

GlaucomaBlindnessRetinal DiseaseDiabetesNone
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Form

Emergency contact

Comprehensive History

Medical History / System Review