Patient Health History Patient Name First Last Birthdate MM slash DD slash YYYY Last Eye Doctor Reason for Last Visit Date of last eye exam MM slash DD slash YYYY Primary Care Physician Date of last visit MM slash DD slash YYYY Contact Lens HistoryBrand of current contact lenses? How often do you replace your contacts? Normal wearing hours? Overnight? Yes No Everyday Wear? Yes No Occasional? Yes No Current Glasses InformationAge of current glasses? 1 yr 2 yr+ Age of sunglasses? 1 yr 2 yr+ Do you use glasses for Computer Sports/Fishing/Hunting Reading Near work/Hobbies Medical AlertsPlease list all medical alerts(i.e., Do Not Dilate, epilepsy, DNR / DNI) Do you take medications for any of these conditions?Diabetes Yes No High Blood Pressure Yes No Kidney Disease Yes No Allergic / Immunologic Yes No Heart Disease Yes No High Cholesterol Yes No Endocrine/Hormonal Yes No Lupus/Arthritis Yes No Glaucoma Yes No Retinal Disease Yes No Macular Degeneration Yes No Thyroid Yes No MedicationsPlease list all prescriptions, over the counter and herbal medicationsPlease list all prescriptions, over the counter and herbal medicationsDateMedication NameStrengthDirections Drug AllergiesAllergyOnset DateReactionSeverity Do you or any close family member have any medical history of: Diabetes Glaucoma High Cholesterol Retinal Disease Cataracts Other Disease Kidney Disease Cancer Macular Degeneration Blindness Dry Eye Heart Disease Eye Injury Strabismus Amblyopia Hypertension Social HistoryWhat type of recreational drugs do you use? What type of alcohol do you drink, how much and how often? Are you a smoker, former smoker or never smoked? Do you smoke everyday or some days? What type of tobacco do you use, how much, how often and for how long? Occupation Work status / duties Hobbies Eye Surgical InformationDateEyeProcedureSurgeonComplications Southern Eye Care Financial Policy We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies. 1. Professional fees are due when services are rendered. A deposit of 50% is required towards the total cost of glasses or contacts before an order can be placed. The balance is due in full at the time of dispensing. We accept personal checks, cash, Discover, Visa MasterCard and CareCredit. 2. When glasses or contacts are purchased through VSP or any other insurance, the balance is due in full when the order is placed. 3. Keep in mind that your insurance policy is basically a contract between you and your insurance company. As a service to you, we will file your insurance claim if you assign the benefits to the doctor. 4. If your insurance company does not pay the practice within 45 days, you are responsible for all fees due. 5. If you are insured by a plan that we do not accept, we will prepare and send the claim for you on an unassigned basis. Therefore, our charges for your care are due at the time of service. 6. Not all-insurance plans cover all services. In the event your insurance plan determines a service to be “not covered,” you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.Signature of patient(or responsible party, if minor)Date MM slash DD slash YYYY Payments can be made through CareCredit at no interest for 6 months. www.carecredit.com or call 1-800-365-8295 to apply.
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