Welcome Back Form

Welcome Back to Professional Family Eyecare
Full Name*

First NameLast Name
Date of Birth
Sex

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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
How did you hear about us?
Parent's Name for Minors
What is the major purpose of this visit?
Current Eyewear and Contacts
Do you have any problems with your current contact lenses or glasses?
Do you wear contacts?

YesNo
Do you sleep in your contacts?

YesNo
Are you satisfied with the vision and comfort of your contacts?

YesNo
How often do you replace your contacts?
Eye Health History
Have you ever experienced, been diagnosed, or treated for any of the following?

Eye InjuryGlaucomaMacular DegenerationBurning / ItchinessTearingFlash of light / FloatersRetinal DetachmentDiabetesDouble VisionCataractsRetinal ProblemsOther
If other, please explain.
Primary Care Information
Primary Care Doctor
Primary's Phone Number
Primary's Location
Medical History
CURRENT MEDICATIONS (List name of medications including eye drops, vitamins, over the counter and birth control pills.)
List all allergies (seasonal/medications)
Have you ever been diagnosed or treated for the following health problems? If yes, please specify below.

AllergiesArthritisBlood/LymphCancerCholesterolDiabetes ? (Insipidus/Mellitus)DigestiveEars/Nose/ThroatEndocrineHigh Blood PressureIntegumentary (Skin)KidneyNeurologicalPsychologicalRespiratoryThyroidOther
If other, please specify.
Family Eye/Medical History
Is there a family history of any of the following

BlindnessRetinal ProblemsGlaucomaMacular DegenerationCorneal ProblemsDiabetesOther
If other, please specify. (Maternal/Paternal)
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.

Minors Child's Name
First Name   Last Name

Child's Date of Birth
Date

Signature of Parent or Legal Guardian
Signature

Relationship to Child
Type a label
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 responsibilities of full payment pending any balance that is not covered by the insurance company.*

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Welcome Back to Professional Family Eyecare

Current Eyewear and Contacts

Eye Health History

Primary Care Information

Medical History

Family Eye/Medical History

Consent To Provide Health Care Services To Minor Child

Patient Financial Responsibility