Retina Consultants of Oklahoma, PLLC Patient Information Sheet Date: First Name: MI: Last Name: Address: City: State: Zip: Phone: ( ) Wk. Phone: ( ) Cell: ( ) Date of Birth: Age: Height: Weight: Sex: q Male q Female Marital Status: q Married q Single q Widowed q Divorced q Other Social Security #: Race/Ethnicity: q American Indian q Asian or Pacific Islander q Hispanic q Non-Hispanic q Black q White q Other q Unknown Employer: Occupation: Email address: Insurance Information Primary Insurance: I.D. #: Group #: Secondary Insurance: I.D. #: Group #: Primary Insured/Responsible Party Information (if different from patient) First Name: MI: Last Name: Address: City: State: Zip: Phone: ( ) Wk. Phone: ( ) Cell: ( ) Date of Birth: Age: Sex: q Male q Female Social Security #: Whom may we thank for referring you? Dr. Referring Doctor s Address (If known): 1
Eye Health What doctor do you normally see for glasses? Doctor s Address (If known): Do you wear glasses? q Yes q No (If yes, how old are your current glasses? ) Have you ever been told you have glaucoma? q Yes Have you ever been told you have cataracts? q Yes q No q No Have you had cataract surgery? qyes qno If so, when? Have you ever had any type of eye surgery (i.e. Lasik/retinal surgery)? q Yes q No If yes, please explain) Have you ever had an eye injury? q Yes q No (If yes, please explain) General Health Please circle Yes or No to indicate if you have or have had any of the following: Yes No Dry Eyes Yes No Depression/Anxiety Yes No Drug Dependency Yes No AIDS/HIV Yes No Arthritis Yes No Asthma Yes No Emphysema Yes No COPD Yes No Bleeding Yes No Blood Clots Yes No Kidney Disease Yes No Lupus Yes No Pace Maker Yes No Seizures Yes No Sleep Apnea Yes No High Blood Pressure Yes No Stroke- If yes, date: Yes No Heart Condition- If yes, what kind? Yes No Diabetes If yes, what type? Type 1 Insulin Dependent Type 1 Non-Insulin Dependent Type 2 Insulin Dependent Type 2 Non-Insulin Dependent Yes No Hepatitis- If yes, what type? Yes No Cancer- If yes, what type? Have you had a Flu shot? qyes qno Have you had a Pneumonia Vaccination? qyes qno 2
Please list all major surgeries and/or illnesses you have had: Please list any medications you are ALLERGIC to and its reaction: Do you use any eye drops? q Yes q No (If so, what kind?) Do you take a blood thinner or aspirin? q Yes q No (If yes, which and what dose?) Please list all prescription medications you are currently taking: (Please Print) Social History Do you smoke? q Yes q No Do you drink? q Yes q No Illicit drug use? q Yes qno What is your current living arrangement: qalone qfamily qspouse qspouse & Kids qfacility qother Do you currently drive? q Yes qno Family History Please circle Yes or No and list if anyone in your family has had a history of any of the following: Yes No Cataracts mother / father / sister / brother / grandmother / grandfather Yes No Macular Degeneration mother / father / sister / brother / grandmother / grandfather Yes No Glaucoma mother / father / sister / brother / grandmother / grandfather Yes No Retinal Problems mother / father / sister / brother / grandmother / grandfather Yes No Diabetes mother / father / sister / brother / grandmother / grandfather Privacy/Emergency Contact Information 3
Relative/Friend whom we may contact regarding your visits and/or in the event of an emergency: 1. Relationship Phone #: ( ) 2. Relationship Phone #: ( ) If our office is unable to reach you by phone, may we leave voicemails regarding your appointments? q Yes q No I certify that I have been provided the Retina Consultants of Oklahoma Notice of Privacy Practices: Patient Signature Date Retina Cons of OK Employee Authorization for Release of Information I,, authorize the release of my protected health information to the person or persons named below. 1. Relationship Phone #: ( ) 2. Relationship Phone #: ( ) Rights of the Patient I understand that I have the right to revoke this authorization at any time. I understand that a revocation is not effective in cases where the information has already been disclosed. I understand that information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. Patient s Signature Date: Authorization of Care I authorize Retina Consultants of Oklahoma, PLLC to examine me and perform such tests and procedures as are reasonable and necessary in the diagnosis and treatment of my care. If I am not the patient, but instead signing on behalf of the patient, I further certify that I am legally authorized to sign on the patient s behalf. Patient s Signature Date: Representative s Signature Date: Relationship of Representative to patient Retina Consultants of Oklahoma, PLLC 4
Lance V. Scott, M.D. 9821 S. May Avenue, Suite C Oklahoma City, OK 73159 (405) 691-0505 Responsible Party Statement and Payment of Benefits I understand that I am financially responsible for all charges that are not directly paid by my insurance company. If the doctor is a participating provider on my insurance I understand that I am responsible for any co-pay, coinsurance ro deductible not paid by my plan. I authorize my insurance company to pay benefits directly to Retina Consultants of Oklahoma/ Lance Scott, M.D. If I do not have insurance I understand that payment is due in full at the time that services are rendered. Patients Name: Patients Signature: Date: Retina Consultants of Oklahoma, PPLC 5
9821 S. May Avenue, Suite C, Oklahoma City, OK 73159 HIPPA Consent Form This consent form must be completed and signed prior to receiving medical treatment from our office. Please return this form to the reception upon completion. I understand that as part of my medical care, this office originates and maintains medical records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I further understand that this information serves as: a basis for planning my care and treatment a means for communication among the health professionals who contribute to my care a source of information for applying my diagnosis and treatment information to my bill and as a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professional By Oklahoma law we are required to notify you.that the information authorized for release may include records which may indicate the presence of communicable or venereal disease which may include, but are not limited to, disease such as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS). Other than myself, my spouse, or others previously identified in the Privacy Notice, this office has permission to use and disclose information regarding my medical care to the following specific person(s): This agreement to release future information shall remain in force until such time as I revoke it in writing. I understand and will be provided with a Patient Privacy Notice, upon request, that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that this office reserves the right to change the notice and practices, but that prior to implementation, a copy of any revised notice will be provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that my doctor is not required to agree to the restrictions requested. I understand that I must revoke this consent in writing, except to the extent the organization has already taken action. Patient s Full Name Signature of Patient or Legal Representative if Minor Printed Name and Relationship to Patient Today s Date (Effective date of notice) 6