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.
Home
Cell
Day
Email
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 Country
Home
Cell
Social 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 History
Please 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.
Signature
Date
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
Signature
For 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

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT

FAMILY Health and Eye History

Retinal Screening

Weiss Eyecare Clinic