Date

Name

First Middle Last

Date of Birth

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

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home

Cell

Social Security Number

Employer

Spouse Name

Birthdate

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

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 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

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

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