Patient Intake Online form PERSONAL INFORMATION MALE FEMALE Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Birthdate* MM slash DD slash YYYY SSNAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone: Text Yes No Cell Phone Work PhoneEmployer Occupation Vision Insurance Carrier Name of Policy Holder Policy Holder Birthdate MM slash DD slash YYYY Policy Holder SSNPolicy Number Medical Insurance Carrier Name of Policy Holder Policy Holder Birthdate MM slash DD slash YYYY Policy Holder SSNPolicy Number Emergency Contact Name Relationship Emergency Contact PhoneEmail Address (Providing this allows us to send appt reminders, order notifications and promotional offers & events)How did you hear about us? MEDICAL & VISUAL HISTORYReason for Today's Visit Glasses Contact Lenses LASIK Surgery Eye Irritation/Pain Last Eye Exam MM slash DD slash YYYY Name of Doctor Please check if you wear Glasses Contact Lenses Age of current pair Age of current pair List any medical conditions you are being treated for and for how long (including pregnancy):List any and all medications you are currently taking (include hormones/birth control/non-prescription/herbal remedies)Are you allergic to any medications? Yes No. No known drug allergies. please list Check all medical conditions that you currently have, or have ever had, in the following areas Allergies/Hay Fever Anemia/Bleeding Arthritis/Muscle Pain Asthma Cancer Cataracts Chronic Bronchitis Chronic Cough Diabetes Dry Throat/Mouth Gastro/Intestinal Headaches/Migraines Head Trauma High Blood Pressure Past Trauma Psychiatric Disorders Seizures Sinus Congestion Skin Rash Thyroid Disease Weight Loss/Gain High Cholesterol Other Type Past Trauma Other Check all eye conditions that you currently have, or have ever had in the following areas Color Deficiency Corneal Transplant Eye Surgery Glaucoma Infection of Eye or Lid Keratoconus Lazy Eye/Strabismus Macular Degeneration Past Eye Injuries Prosthesis Ptosis (drooping lid) Retinitis Pigmentosa Blurred Vision Distance Blurred Vision Near Distorted Vision (halos) Double Vision Dry Eyes/Redness Epiphora (excess tearing) Eye Pain or Soreness Floaters or Spots Night Vision Problems Sandy/Gritty Feeling Tired Eyes Vision Therapy Other Type Type Past Eye Injuries Other Check conditions that are present in other family members Cancer Cataracts before age 60 Other eye diseases Other Inherited Conditions Diabetes Glaucoma Heart Disease High Blood Pressure High Cholesterol Macular Degeneration Stroke/TIA's Cancer please list please list CONTACT LENS HISTORYHave you ever worn contacts? Yes No Are you here for a contact lens prescription today? Yes No When was the last time you wore contacts? How many days a month do you sleep in your contacts? Please check which kind of contacts you currently wear or are interested in: Daily Disposable Rigid Gas Permeable Monthly Wear Bifocal/Monovision Colors Other Other Problems with contacts dry uncomfortable blurry other Brand of current contacts Solution you currently use SOCIAL HISTORY, HOBBIES & INTERESTS Indoor/Outdoor Sports Musical Instruments Exercising Tobacco Products Travel/Vacation Alcohol Swim Recreational Drug Use Computers Reading Other hrs/day Other NOTICE OF PRIVACY PRACTICESHIPAA - Patient Consent for use and disclosure of protected health information I hereby give my consent for Wind City Eye Care to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Wind City Eye Care's Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent.Wind City Eye Care reserves the right to revise its Notice of Privacy Practices at anytime. With this consent, Wind City Eye Care can call me at home or other alternate locations and leave a message or voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, obtaining insurance information, billing and any calls pertaining to my clinical care. With this consent , Wind City Eye Care may mail to my home or other alternative locations any items that assist the practice in carrying out TPO, such as appointment reminder cards, statements and/or insurance information. By signing this form, I am consenting to V EYE P the use and disclose of my PHI to carry out TPO. My signature below signifies my understanding and willingness to comply with the above policies. Signature of patient (or guardian)*Date* MM slash DD slash YYYY ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITYWhen provided the necessary insurance information prior to an appointment, the staff of Wind City Eye Care makes every attempt to verify patient's benefits. In addition, the staff will gladly file insurance claims on behalf of the patient. The insurance carrier will review the claim and accept or deny coverage as they deem appropriate. Should the insurance company deny coverage, it is the patient's responsibility to pay any and all of the balance to Wind City Eye Care. To be better prepared, patients should attempt to know their coverage including deductibles, co-pays and noncovered services. The staff of Wind City Eye Care can give you a general idea of what may or may not be covered by your insurance plan before seeing the doctor. However, we cannot always know for certain what services will be provided by the doctor before the examination. Whether a visit will be filed with a vision carrier or medical carrier is dependent on several factors including but not limited to patient's reason for visit, type of exam performed, and diagnoses. Any diagnosis other than a routine diagnosis will result in a medical claim submittal. At times, patients may be able to use both medical and vision benefits to maximize patients' benefits. By signing below, I acknowledge that I have read and understand the above.Signature of patient (or guardian)Date MM slash DD slash YYYY SIGNATURE ON FILE I AUTHORIZE THE USE OF THIS FORM ON ALL MY INSURANCE SUBMISSIONS. I AUTHORIZE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPANIES. I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL I AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN HELPING OBTAIN PAYMENT FROM MY INSURANCE COMPANIES I AUTHORIZE PAYMENT DIRECT TO MY DOCTOR. I AUTHORIZE A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. I AUTHORIZE EMAILS & TEXT MESSAGES BE SENT TO ME FOR APPT REMINDERS, ORDER NOTIFICATIONS AND PROMOTIONAL OFFERS & EVENTS Signature of patient (or guardian)Date MM slash DD slash YYYY CREDIT CARD PAYMENT AUTHORIZATIONWhen provided the necessary payment information at the end of an appointment, the staff of Wind City Eye Care makes every attempt to verify each patient's form of payment. Under state and federal law, it is legal to allow another party to utilize your credit card with your permission. As the cardholder, you are in agreement to be held liable for any purchases that person(s) makes. I understand the information that is listed above and I am in full agreement that is approved to utilize my credit card as a form of payment to Wind City Eye Care for medical, vision, and/or optical expenses. I agree that I will be responsible for all charges and that this purchase will not be covered by my card's protection. By signing below, I acknowledge that I have read and understand the above.Signature of patient (or guardian)Date MM slash DD slash YYYY Untitled CommentsThis field is for validation purposes and should be left unchanged.
