New Patient Paperwork Date MM slash DD slash YYYY Name First Middle Last Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SS# (for insurance purposes) male female We send all appointment reminder, annual exam recalls, and eyewear notifications by email and/or cell phone text message. Please provide both to ensure continuity care. HomeCellDayEmail Preferred Language Race/ Ethnicity: African American Asian Caucasian Hispanic/ Latino Native American Marital Status : Single Married Separated Divorced Widowed PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT(Fill this out if patient is under 18)Name First Last Birth of Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HomeCellSocial Security Number Employer Spouse Name Birthdate MM slash DD slash YYYY Spouse Employer Please list all family members living with you and their birthdates:Occupation Employer/School Employed Full time Employed Part time Full time Student Part time Student Medical physician Date of last physical Previous eye doctor Date of last exam MM slash DD slash YYYY Reason for today’s visit Do you wear glasses? Yes No Do you wear contact lenses? Yes No Do you wear sunglasses? Yes No Are they polarized? Yes No I am interested in: Updating My Glasses Safety Glasses Polarized Sunglasses Decreasing Glare from Snow/Water/Sunlight Reading Glasses Computer Glasses Transition Lenses Fun Pair of Glasses Contact Lenses Other How did you hear about us? Hobbies Current Medications:OTC/Vitamins:Eye Drops:Medication Allergies:Tobacco Use: I have NEVER used tobacco I am a CURRENT tobacco user I am a FORMER tobacco user Your Health History (check all that apply) Diabetes 1 Diabetes 2 Thyroid Disease High Blood Pressure High Cholesterol Heart Disease Rheumatoid Arthritis Rheumatoid Arthritis Seasonal Allergies Autoimmune Disease: Cancer (type): Other: Pregnant Yes No Number of weeks Your Eye History (check all that apply) Eye Discharge Cataracts Strabismus Macular Degeneration Eye Strain Eye Pain Glaucoma Iritis/Uveitis Lazy Eye Retinal Detachment/Tear Redness Floaters/Spots Double Vision Dry Eyes Flashes of Light Sensitive to Light Foreign Body Eye Surgery: Year Eye Surgeon: FAMILY Health and Eye HistoryPlease list WHO in your family (mother, father, brother, sister, maternal grandma, maternal grandpa, paternal grandma, paternal grandpa, aunt, uncle)Diabetes: Cataracts Thyroid Disease Glaucoma Heart Disease Macular Degeneration High Cholesterol Hypertension Retinal Detachment Other Retinal Screening The doctor prefers ALL patients have a digital image of the retina taken annually using the Optomap digital imaging system. Retinal problems such as macular degeneration, retinal holes, retinal tears, retinal detachments, growths and diabetic retinopathy can be seen without dilation for most patients. EARLY DETECTION IS CRUCIAL! Optomap Retinal Screening Advantages: Retinal image becomes a permanent part of your medical record A complete view of the entire retina is seen quickly without dilation drops No blurred vision or light sensitivity because drops are not needed No wasted time waiting as your eyes dilate **The Optomap is $40.50 (if paid the same day) and is not covered by insurance.** Contact Lens Exam A routine eye exam will provide a prescription for eyeglasses only. If you are a contact lens wearer, there is a separate fee for the contact lens evaluation. Insurance companies do not cover this fee. The fee ranges from $45-$80 for patients who currently wear contacts and $90-$125 for patients who are requesting a first time fitting. INITIALS Financial Policies I understand that Weiss Eyecare Clinic will help facilitate my insurance benefits, but that is ultimately my responsibility to know the terms and conditions of my medical or vision coverage. Most insurance policies pay only a portion of your total charges. If you have any questions about your coverage, please contact your representative. We do not guarantee the accuracy of benefit information given to us by insurance companies.> I understand that depending on my eye problem(s) and the doctor’s assessment, my medical and/or vision insurance may be billed. I understand that vision plans only provide coverage for routine eye examinations, glasses and contacts. They do not provide coverage for any medical problems I may be having, such as dry eyes, diabetes, cataracts, glaucoma, etc. I authorize the release of any medical or other information necessary to process any insurance claims. I also authorize payments of medical benefits to Weiss Eyecare Clinic for services and/or materials. The cancellation of any order is subject to fees incurred. We use private optical labs to process your prescription. Due to the custom nature of eyewear orders we are unable to cancel once ordered.SignatureDate MM slash DD slash YYYY Please select and initial all of the following statements that apply to you:I use on-line contact lens ordering and would like to authorize release of my contact lens info. I give your office permission to leave messages on the phone number on record I understand that my medical information will be shared with referring providers and/or my primary medical doctor. Only individuals listed on my signed HIPAA form (see below) can have access to my info. I understand that privacy laws are Federal Requirements that must be adhered to. Complaints: If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the US Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office address, fax or email. If you prefer, you can discuss your complaint in person or by phone. Changes to This Notice: We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area. ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I received a copy of Weiss Eyecare Clinic’s Notice of Privacy Practices. Date MM slash DD slash YYYY Name First Last SignatureFor patients over 18 years and older: Please list below the individuals that can have access to my information, which may include exam results, material cost, ledger balance, etc.: Name First Last Relationship Name First Last Relationship Name First Last Relationship Name First Last Relationship
