Patient Health History

Name: Southern Eye Care Associates
Address: 140 Main St W, Oak Hill, WV, 25901, US
Telephone: 304-469-6711
Price range: $000 - $300

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 History
Brand 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 Information
Age 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 Alerts
Please 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
Medications
Please list all prescriptions, over the counter and herbal medications
Please list all prescriptions, over the counter and herbal medications
Date Medication Name Strength Directions
Drug Allergies
Allergy Onset Date Reaction Severity
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 History
What 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 Information
Date Eye Procedure Surgeon Complications
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.

Date	Medication Name	Strength	Directions

Allergy	Onset Date	Reaction	Severity

Date	Eye	Procedure	Surgeon	Complications

Contact Lens History

Current Glasses Information

Do you take medications for any of these conditions?

Medications

Drug Allergies

Social History

Southern Eye Care Financial Policy

Southern Eye Care Associates

We will be accepting WV PEIA EyeMed Vision Insurance from July 1st