Patient s Full Legal Name: DOB: Sex: M F. SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip:
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1 Patient Information: Date: Patient s Full Legal Name: DOB: Sex: M F SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip: Home Phone: Cell Phone: Daytime Phone: Approved Communication: (circle all applicable) Text Phone Mail Employment/Student Status: (circle one) Full Time Part Time Retired Unemployed Student Employer: Occupation: How did you hear about us? Insurance Information: Medical Insurance: Phone #: Member/Subscriber ID #: Group/Acct #: Vision Insurance: Phone #: Member ID #: Group/Plan #: *If you are not the guarantor/primary policy holder, please enter that individual s information below: Guarantor s Name: Relationship to Patient: (circle one) Spouse Parent Other DOB: SS#: Sex: M F Employer: Address: City: State: Zip: Home Phone: Cell Phone: Daytime Phone: Please note that the above information is required in order for us to file your examination to your insurance. Please do not leave any section blank as it will delay filing your insurance and may result in a denial from your insurance company.
2 Required Signatures: Financial Policies and Patient Responsibility: Vision Veritas does its best to accurately obtain your coverage and charge you in accordance to your insurance benefits. While we will do everything we can to keep you informed of covered vs. non-covered services (as quoted by your insurance company), final determination of coverage and payment is not made until your insurance claim is reviewed by your insurance company. By signing below, you understand that payment collected today is based on a quote from your insurance company and is not a guarantee of benefits. In cases where professional goods and services are not covered (therefore, denied) by your insurance company, it will be the patient s responsibility to pay for these services in full. Claims not paid due to errant or undisclosed insurance information provided by the patient will be the responsibility of the patient as well. If we are not on your insurance plan, we require full payment for all services and products at the time they are rendered, but will provide you with an itemized receipt that you may submit to your insurance plan for potential reimbursement. I have read and understand the financial policy of Vision Veritas and I do accept financial responsibility: Vision vs. Medical Insurance and Assignment of Insurance Benefits: Vision insurance coverage is designed to cover routine eye services and to determine a glasses and/or contact lens prescription. When a medical condition or diagnosis is present, it may be necessary to file your examination to your medical insurance. Many times, we may not be aware of any medical diagnosis beforehand. These rules are often dictated by the insurance carriers themselves. Should this situation arise, we will do our best to inform you as to whether we will file your examination to your vision or medical insurance. In either case, the patient is responsible for any financial responsibility as dictated by their respective insurance company. I authorize the payment of my medical/vision benefits to Vision Veritas. I authorize Vision Veritas to release any information required to process any and all claims for reimbursement on my behalf. A copy of this authorization may be used in place of the original. Consent to Treat a Minor: By law, any child under 18 years of age cannot be seen by a doctor without consent from a parent or legal guardian. If a child arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf. Name of individual who may act on Parent/Legal Guardians behalf: (Name) (Relation to Patient) Signature of Parent/Legal Guardian: Date: My signature below verifies that I have reviewed a copy of the HIPAA Privacy Statement. I authorize Vision Veritas to disclose information about my medical conditions/treatment to the following individuals: Name(s): Relationship: Phone:
3 VISION VERITAS MEDICAL HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Date: / / Date of Birth: / / Gender: Last Medical Exam: / / Dr. s Name: Last Eye Exam: / / Dr. s Name: Pharmacy Tel/Fax: OCULAR/MEDICAL HISTORY Do you have any allergies to medications? Yes No If yes, explain: List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): List all major injuries, surgeries and/or hospitalizations you have had: Do you have or have you Glaucoma Cataracts Lazy eye Cross eye Eye Infection Retinal Hole/Detach. ever had? Macular Degeneration Eye Surgery Eye Injury Diabetes Autoimmune Disease High Blood Pressure Thyroid Disease Cancer Other condition not listed: Are you pregnant? No Yes Are you nursing? No Yes Do you wear glasses? No Yes How old? Comfortable to wear? No Yes Do you wear contacts? No Yes How old? Comfortable to wear? No Yes Lens Type: Rigid Soft Extended Wear Other FAMILY HISTORY Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: CONDITION NO YES? RELATION CONDITION NO YES? RELATION Blindness: Cancer: Cataract: Diabetes: Crossed Eyes: Heart Disease: Macular Degeneration: High Blood Pressure: Retinal Detachment: Kidney Disease: Glaucoma: Multiple Sclerosis: Thyroid Disease: Other: SOCIAL HISTORY (This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.) Yes I would prefer to discuss my Social History information directly with my doctor. Do you use tobacco products? No Yes Type/Amount/How long: / / Do you drink alcohol? No Yes Type/Amount/How long: / / Do you use illegal drugs? No Yes Type/Amount/How long: / / Do you drive? No Yes Visual difficulty when driving? No Yes Have you been exposed/infected with: HIV Hepatitis Gonorrhea Syphilis Herpes ~Please turn this form over and complete side two~
4 REVIEW OF SYSTEMS Do you currently, or have you ever had any problems in the following areas: CONSTITUTIONAL EARS, NOSE, MOUTH, THROAT Fever: No Yes? Allergies/Hay Fever: No Yes? Recent Weight Loss/Gain: No Yes? Sinus Congestion: No Yes? INTEGUMENTARY (Skin) Runny Nose: No Yes? Rash: No Yes? Post-Nasal Drip: No Yes? Itching: No Yes? Chronic Cough: No Yes? Moles: No Yes? Dry Throat/Mouth: No Yes? NEUROLOGICAL RESPIRATORY Headaches: No Yes? Asthma: No Yes? Migraines: No Yes? Emphysema: No Yes? Seizures: No Yes? Sleep Apnea: No Yes? Dizziness: No Yes? VASCULAR / CARDIOVASCULAR Numbness / Tingling: No Yes? Heart/Chest Pain: No Yes? EYES High Cholesterol: No Yes? Loss of Vision: No Yes? High Blood Pressure: No Yes? Blurred Far Vision: No Yes? Vascular Disease: No Yes? Blurred Near Vision: No Yes? GASTROINTESTINAL Distorted Vision/Halos: No Yes? Diarrhea: No Yes? Loss of Side Vision: No Yes? Constipation: No Yes? Double Vision: No Yes? GENITOURINARY Night Vision Problems: No Yes? Kidney Stones: No Yes? Color Vision Problems: No Yes? Difficult Urination: No Yes? Dryness: No Yes? Incontinence: No Yes? Mucous Discharge: No Yes? Genital Problems: No Yes? Redness: No Yes? BONES / JOINTS / MUSCLES Sandy or Gritty Feeling: No Yes? Rheumatoid Arthritis: No Yes? Itching: No Yes? Muscle Pain/Weakness: No Yes? Burning: No Yes? Joint Pain/Weakness: No Yes? Excess Tearing/Watering: No Yes? LYMPHATIC / HEMATOLOGIC Glare/Light Sensitivity: No Yes? Anemia: No Yes? Eye Pain or Soreness: No Yes? Bleeding Problems: No Yes? Infection of Eye/Lid: No Yes? ALLERGIC/IMMUNOLOGIC Foreign Body Sensation: No Yes? Sjögrens: No Yes? Sties or Chalazion: No Yes? Lupus: No Yes? Flashes in Vision: No Yes? Other (including Multiple Sclerosis): No Yes? Floaters in Vision: No Yes? PSYCHIATRIC ENDOCRINE Memory loss/ Confusion: No Yes? Thyroid: No Yes? Panic Attacks: No Yes? Diabetes: No Yes? Insomnia: No Yes? If you answered YES to any of the above or have a condition not listed, please explain & list medications: DOCTOR S/STAFF SIGNATURE DATE
5 EyeScreen Photographic Examination We at Vision Veritas are pleased to provide our patients with an advanced digital retinal exam called EyeScreen. EyeScreen is a high resolution screening photograph of your retina which will help us document, review, and compare your retina over time. We will use the EyeScreen exam to document a baseline image for our charts, screen for eye diseases and improve our ability to view your internal retinal health at a much higher resolution than a slit lamp or ophthalmoscope. We are concerned about retinal problems such as macular degeneration, glaucoma, retinal holes, detachments, and diabetic retinopathy (all of which can lead to partial loss of vision or blindness). Additionally many symptoms of systemic diseases such as diabetes and the effects of high blood pressure can be detected with the EyeScreen Examination. You can expect from this exam: An annual eye wellness EyeScreen photograph An in depth view of the retinal surface (where eye diseases first manifest) The ability to review the images with you (we will show you your retina) A permanent record for your medical file, for serial analysis, comparisons, and diagnosis To be fast, easy and comfortable Since insurance will only pay for retinal photos after eye disease is discovered the EyeScreen Examination is an out of pocket expense. Drs. Anita and Olivia Carleo recommend this procedure for all of his patients and will perform the EyeScreen Exam at an additional cost of $23 to the basic eye exam you are receiving today. Please select one of the following boxes. I AGREE TO have my retinal health evaluated with the EyeScreen Exam. Please read and sign below. I DO NOT wish to have the Retinal Photographic Exam. I understand the importance of the EyeScreen Exam but elect not to have it done this year. Patient Signature Date
Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA Phone: Fax:
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More informationPatient s Full Legal Name: DOB: Sex: M F. SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip:
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Main: 136 W. Cherry St Jesup, GA 31545 Brunswick: 17 Professional Dr Suite 100 Brunswick, GA 31520 Ophthalmology Phone: (912) 559-2467 Fax: (912) 559-2473 www.crandalleye.com Dear, Thank you for choosing
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More informationWe look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
Welcome to Biltmore Eye Physicians! Enclosed in our new patient packet are the following items: 1. Patient Registration 2. Credit Policy and Financial Agreement 3. Notice of Privacy Practices 4. Medical
More informationName (Last, First, MI): Date of Birth: / /
Name (Last, First, MI): Address: Age: City: State: Zip: Sex: Male / Female Phone #: (Home): (Cell): (Work): Personal Email: Social Security #: Race: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Other
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Patient Information Date Patient Name (First) (M.I.) (Last) Date of Birth SSN Gender Male Female Transgender-Male Transgender-Female Marital Status Race Ethnicity Preferred Language Patient Address City
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METROPOLITAN EYE CARE Scott B. Pomerantz, M.D. Thomas J. LoPresti, O.D Lori R. Kaplan, O.D. 523 Forest Avenue Paramus, NJ 07652 Tel. (201) 262-5070 Fax (201) 262-5333 Please Complete and Sign Where Indicated
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