Burnet Eye Care & Llano Eye Care P.O. Box 426 Burnet, TX phone 102 E Young St Llano, TX phone

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1 Burnet Eye Care & Llano Eye Care P.O. Box 426 Burnet, TX phone 102 E Young St Llano, TX phone PATIENT REGISTRATION Patient s Name Today's Date Mailing Address City State Zip Social Security # - - Date of Birth Gender F M Cell ( ) - Home ( ) - Work ( ) - Employer Occupation Is it OK for us to leave a message at your place of employment? Y N Preferred Method of contact: Home phone Cell phone Work phone Mail Race: American Indian/Alaskan Native Asian Black/African American White Native Hawaiian/Pacific Islander Other race Ethnicity: Not Hispanic/Latino Hispanic/Latino Unknown Primary Language: English Spanish Other IF PATIENT IS A MINOR: Parents/Guardian's name Social Security # Date of Birth Do you have MEDICARE? Y N MEDICAID? Y N HEALTH INS? Y N VISION PLAN? Y N Name of Medical Insurance: Name of Vision Plan: Exams for contact lenses require additional fees for service. Do you currently wear contact lenses? Y N Do you want to talk to the Doctor about contacts today? Y N Contact lens wearers, please initial here to indicate that you have read and understand our Contact Lens Agreement. Are you currently living in a SNF (skilled nursing facility) for rehabilitation only? Y N Name of facility Phone( ) - Mailing address City State Zip Are you interested in receiving information about quitting smoking? Y N Are you interested in receiving information about weight/nutrition counseling? Y N

2 AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION *If you are 18 or older and you want another person or family member to have access to your medical records, account information, or prescription you must sign this authorization box. I authorize Burnet Eye Care / Llano Eye Care to release health information identifying me under the following conditions: Any and all visual and/or personal health information and/or account information in my records to: Signing this authorization is voluntary. If you sign this authorization, you may revoke it at any time by contacting our Privacy Officer in writing as noted in the Notice of Privacy Practices. Patient name printed Patient signature Date CONTINUITY OF CARE DOCUMENT (CCD) If you would prefer to receive the exam summary data including your current medication list, allergies, and diagnosis list (CCD) electronically please provide your address. You will receive an with a link to access your CCD. address: PAYMENT, INSURANCE / VISION PLANS, and FINANCIAL INFORMATION Payment is due at the time services are rendered. Cash, Check, Visa, MasterCard, Discover, and American Express are accepted as payment. Please present ALL insurance cards at the front desk when you arrive. We are UNABLE to make a claim on your insurance or vision plan AFTER the date of service. Burnet/Llano Eye Care contract with many insurers and vision plans to accept assignment of benefits. We will bill those plans for which we have an agreement and will only require you to pay the authorized co-payment/co-insurance at the time of service. If it is determined that you do not have benefits to cover today s visit, you have been seen out of network, or your insurance determines a service not covered, please understand that you are responsible for payment for today s services. I certify that the insurance information given by me is true and correct. I authorize the doctor to act as my agent in helping me obtain payment of my insurance benefits, and I request that payment of these benefits be made on my behalf to Burnet/Llano Eye Care for any services and materials furnished. I authorize Burnet/Llano Eye Care to release any information necessary to insurance carriers regarding my diagnosis and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing. Accounts that become delinquent may be referred to a collections agency and you are responsible for collection costs in addition to your outstanding balance. There is a $30.00 fee for checks returned by the bank. CANCELLATION POLICY If unable to keep your appointment, kindly give 24 hours notice; otherwise we reserve the right to charge for time reserved. CONSENT TO TREAT I have requested medical services from Burnet/Llano Eye Care on behalf of myself and/or my dependents. I agree to and understand that my Doctor may request that my eye(s) be dilated in order to thoroughly check the retina. I agree to and understand that my eye(s) may need to be patched as part of treatment. I understand that if my pupils are dilated or my eye is patched after the eye exam, I may not be able to safely operate a motor vehicle and that the staff and doctors of Burnet/Llano Eye Care request and urge that I arrange alternate transportation. ACKNOWLEDGEMENT OF PRIVACY PRACTICES AND POLICIES DEFINED ABOVE I have been made aware of and/or reviewed this office s Notice of Privacy Practices, which explains how my medical information may be used or disclosed. I understand that I am entitled to receive a copy of this document upon request. Signature of responsible party: Date:

3 Burnet Eye Care & Llano Eye Care Medical History Form Today s date _Patient name Date of birth Previous Eye Doctor Date of last visit Address Primary Physician Address Medications and Allergies Current medications (or please provide us with a list of medications) Are you allergic to any medications? Yes No Provide details if yes. Surgical Information Date Eye Procedure Surgeon Complications Review of Systems Please mark those that apply to you. High blood pressure Heart attack Congestive heart failure Chest pain (angina) Irregular heart beat Emphysema Asthma Bronchitis Shortness of breath Frequent cough Ulcer Frequent heartburn Hepatitis Colitis / diverticulitis Kidney disease (on dialysis) Enlarged prostate Skin disorders Autoimmune disorder Infectious disease Arthritis Muscular dystrophy Injury to extremity Stroke Parkinson s disease Tremors Migraine or other severe headache Multiple sclerosis Anemia or swollen glands Eczema, hives Hay fever Anxiety Depression Psychiatric illness Diabetes Thyroid disease HIV/AIDS Cancer Weight gain/loss Unexplained fatigue Unexplained fever Sinusitis Nose or throat problems Hard of hearing Other

4 Diabetic Information If you are diabetic or taking medication for diabetes, please complete: SMBS: Self-Monitoring Blood Sugar Test AND/OR HgbA1c:Hemogloin A1c test Date Type of test SMBS HgbA1c Value fasting post-breakfast post-lunch post-dinner Date Type of test SMBS HgbA1c Value fasting post-breakfast post-lunch post-dinner Past/Present Ocular History Please list any past or present ocular illnesses, symptoms or problems Glaucoma Cataracts Age-related Macular Degeneration Eye Injury Retinal Disease/Detachment Blindness Strabismus Amblyopia (lazy eye) Diabetes Dry Eye Other Date diagnosed Family History Have you or a family member ever had: Glaucoma you family Macular degeneration you family Cataracts you family Retinal disease/detachment you family Amblyopia (lazy eye) you family Vascular disease you family Eye injury you family Blindness you family Strabismus you family Stroke you family Heart disease you family Hypertension you family Cancer you family High cholesterol you family Diabetes you family Kidney disease you family Other Social history Never Smoked Previous Smoker: Year quit smoking Current Smoker: packs per day Do not drink alcohol Socially/Occasionally drink alcohol Drink alcohol 3 or less per week Drink alcohol 4 or more per week Women:

5 Are you pregnant? yes no Are you currently nursing? yes no Contact Lens History If you currently wear contact lenses please indicate: Hard lenses Soft lenses Extended wear (you sleep in them) Manufacturer Lens name Power Right eye Left eye Base curve Diameter Number of hours worn daily How often do you replace them? Daily 2-3 weeks Monthly Other Computer How many hours per day do you work on a computer?