Welcome to Form

Welcome to Professional Family Eyecare
Patient Information
Full Name*

First NameLast Name
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex

MaleFemaleOther
Cell Phone*
Home/Work Phone
Please enter a valid phone number.
Patient's SSN
Employer (or School)
Occupation (or Grade)
E-mail*
example@example.com
Parent's Name for Minors
How did you hear about us?*
Eye Exam History
Date of Last Eye Exam?
By Whom?
Do you currently wear contact lenses?

YesNo
Primary Care Information
Primary Care Doctor
Primary Phone Number
Primary's Location
Family Eye/Medical History (Check all that apply)
Is there a family history of any of the following:

BlindnessRetinal ProblemsGlaucomaMacular DegenarationCorneal ProblemsDiabetesOther
If yes, please list which family member(s)?
Medical History
CURRENT MEDICATIONS (List name of medications including eye drops, vitamins, & birth control pills):
List all allergies (seasonal/medications)
Do you use:

AlcoholOther substancesCigarettes/Tobacco
When did you start smoking?
If yes, how much do you smoke? blanks
Have you ever been diagnosed or treated for the following health problems? If yes, please check below.

ArthritisCancerCholesterolDiabetes (Insipdus/Mellitus)High Blood PressureIntegumentary (Skin)KidneyNeurologicalPsychologicalRespiratoryThyroid (Hyper/Hypo)Other
Eye Health History

Have you ever experienced, been diagnosed, or treated for any of the following?
Type a question

CataractsGlaucomaMacular DegenarationCrossed eye / Eye TurnFlash of light / FloatersItchinessRetinal DetachmentDiabetesDouble VisionEye InfectionsTearingCorneal AbrasionsOther
Consent To Provide Health Care Services To Minor Child

Fill Out For Minors Only.
I, First Name   Last Name (parent or legal guardian), give consent to Professional Family Eyecare to arrange, schedule, and/or provide health care services, including the administration of topical anesthetic drops and a prescription for medicinal drugs, if needed, to First Name   Last Name , as deemed necessary for the health and welfare of said minor child. This authorization is effective from the date of signature.

Minor Child's Name
First Name   Last Name

Signature of Parent or Legal Guardian
Signature

Relationship to Child
Type a label

Date
Patient Financial Responsibility ( I hereby authorize Professional Family Eyecare to apply my vision benefits on my behalf for covered services rendered. I agree to assume responsibility of full payment pending any balance that is not covered by insurance company. Patient or Guardian's Signature.*

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HIPAA Compliance Acknowledgement of Receipt of Privacy Notice. (Professional Family Eyecare respects the privacy of our medical records and will do all that we can do to secure and protect that privacy. I have reviewed or received a copy of the Notice of Privacy Practice from Professional Family Eyecare. I authorize Professional Family Eyecare to use my information to submit my vision benefit claim.*

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Should be Empty:

Welcome to Professional Family Eyecare

Patient Information

Eye Exam History

Primary Care Information

Family Eye/Medical History (Check all that apply)

Medical History

Eye Health History

Consent To Provide Health Care Services To Minor Child