New Patient Form

 

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Which office would you like your information sent to:

Polaris office
Lane Avenue office
Both offices


Patient Information

Salutation
Name:
Email Address:
Home Phone: Preferred phone
Other Phone: Preferred phone
Address:
City:
State:
Zip:



Date of Birth
Social Security Number
Gender MaleFemale
Marital Status Single Married Other
Employer
Occupation




Medical History Information

Briefly describe any eye problems that you are having:
If you have glasses, when do you wear them?
Do you currently wear contact lenses? Yes No
   If so, what type: Hard / Gas Permeable Soft
   How long do you wear them?
If you do not wear contacts, are you interested in contacts? Yes No Maybe
When was your last exam?
   Name of the eye doctor:
Name of your family doctor:
List any previous eye surgeries:
Hours a day spent on the computer hours/day
List any drug allergies:
Current medications:



Family History

Condition No Yes Self Family Member Relationship to family member
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment or Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
Other



Soical History

Do you drive? No Yes
   If yes, do you have visual difficulty when driving? No Yes Describe:
No Yes Type / Amount / Frequency
Do you use tobacco?
Do you use alcohol?
Do you use illegal drugs?
Have you been exposed to or infected with: Gonorrhea
Hepatitis
HIV
Syphilis
None



Review of Systems

Do you currently, or have you recently had any problems in the following areas:


Constitutional
Fever, Weight Loss/Gain No Yes ?
Intergumentary
Skin No Yes ?
Neurological
Headaches No Yes ?
Migraines No Yes ?
Seizures No Yes ?
Eyes
Loss of Vision No Yes ?
Blurred Vision No Yes ?
Distorted Vision/Halos No Yes ?
Loss of Side Vision No Yes ?
Double Vision No Yes ?
Dryness No Yes ?
Mucous Discharge No Yes ?
Redness No Yes ?
Sandy or Gritty Feeling No Yes ?
Itching No Yes ?
Burning No Yes ?
Foreign Body Sensation No Yes ?
Excess Tearing/Watering No Yes ?
Glate/Light Sensitivity No Yes ?
Eye Pain or Soreness No Yes ?
Chronic Infection of Eye or Lid No Yes ?
Sties or Chalazions No Yes ?
Flashes / Floaters in Vision No Yes ?
Tired Eyes No Yes ?
Endocrine
Thyroid/Other Glands No Yes ?
Ears, Nose, Mouth, Throat
Allergies/Hay Fever No Yes ?
Sinus Congestion No Yes ?
Runny Nose No Yes ?
Post-Nasal Drip No Yes ?
Chronic Cough No Yes ?
Dry Throat/Mouth No Yes ?
Respiratory
Asthma No Yes ?
Chronic Bronchitis No Yes ?
Emphysema No Yes ?
Vascular/Cardiovascular
Diabetes No Yes ?
Heart Pain No Yes ?
High Blood Pressure No Yes ?
Vascular Disease No Yes ?
Gastrointestinal
Ulcers No Yes ?
Other No Yes ?
Genitourinary
Genitals/Kidney/Bladder No Yes ?
Bones/Joints/Muscles
Rheumatoid Arthritis No Yes ?
Muscle Pain No Yes ?
Joint Pain No Yes ?
Lymphatic/Hematologic
Anemia No Yes ?
Bleeding Problems No Yes ?
Allergic/Immunologic No Yes ?
Psychiatric No Yes ?

If you answered YES to any of the above or have a condition not listed, please explain and list medications:



Initials: Date:

Read carefully, sign and date: I understand that all fees are due and payable at the time of service unless other arrangements have been made and agreed upon. As a courtesy to me, the patient, this office will file insurance claims for payment in accordance with the information I have provided. I am responsible to provide proof of insurance, accurate and complete patient and billing information, and for obtaining proper referrals and preauthorization, in accordance to the provision of my vision or health care plan, for all services/ procedures rendered to me by my physician. I understand and request that payment of authorized Medicare/other insurance company benefits be made directly to Horvath Vision Care, Inc. on my behalf for all services/procedures rendered. I authorized any holder of medical information about me to release any pertinent information needed to determine these benefits or the benefits payable to related services/ procedures. I understand and agree that if my physician agrees to accept the determination of the insurance company as full payment, then I am only responsible for co-pay, co-insurance, deductible and non-covered service/procedure amounts. I agree to pay my portion(s) due at time of service or immediately upon receipt of a statement from Horvath Vision Care, Inc.