Patient Welcome Form Patient Name: First Middle Last Date of Birth: Sex:MaleFemaleSocial Security #:Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Cell Phone:Work Phone:RaceHispanicWhiteAmerican IndianAsianBlack/African AmericanNative AmericanEthnicityHispanic or LatinoNot Hispanic or Latino (Caucasian)Native AmericanArabBlack/African AmericanNative Hawaiian or other Pacific IslanderPreferred LanguageEnglishSpanishArabicFrenchEmail Addressfor appointment reminders and notification of glasses and contacts Communication Preferences:Home PhoneCell PhoneWork PhoneEmailPostalCan we leave a message regarding test results?YesNoEmployer:Occupation:If Minor, Name of Guardian: First Last If Married, Spouse’s Name: First Last In the event of an emergency whom can we contact? Name Phone Whom may we thank for referring you to our office?Friend/Family memberPhone BookSearch EngineWebsiteInsurance ListingNewspaperHealth Insurance Portability and Accountability Act-HIPAAPlease specify:Health Insurance Portability and Accountability Act-HIPAA We respect the legal obligation to keep your health information private. The most common reason why we use or disclose your health information is for treatment, payment, or health care operations. If you would like a copy of our Notice of Privacy Practice please let the front desk know. By signing below it means that you are aware of our privacy practices and that you have been given the opportunity to obtain a copy of our policy.SignatureDate Payment InformationPayment Information Payment is expected at the time services are rendered. Accounts left unpaid after 120 days will automatically be turned over for collections along with a $35 service charge. I understand that I will receive a statement after 30 days if the insurance has not paid. I further understand that I am responsible for the total amount due or any amount unpaid by the insurance. Any denial or dispute of payment by my insurance company is my responsibility. If insurance is being billed by our office, this signature serves as your “signature on file”.SignatureDate Authorization for Release of InformationAuthorization for Release of Information Many of our patients allow family members to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to a family member, you must list the family/friend and sign below. I authorize Eyecare Associates to release my medical and/or billing information to the individuals listed below. I understand I have the right to revoke this authorization at any time and that I have the right to inspect or receive a copy of the PHI to be disclosed.1. Name Relation to patient 2. Name Relation to patient SignatureDate VISION HISTORYDate of last eye exam: Previous eye doctor or clinic:Are you currently using medication eye drops?Please listSelfFamily Member(s)GlaucomaMacular DegenerationCataractsDiabetic Eye DiseaseRetinal DetachmentsKeratoconusAmblyopiaEye TurnsEye SurgeriesEye AllergiesEye InjuriesEye InfectionsPlease describe any conditions marked above, and the how the family member is related to you, if applicable:HEALTH HISTORYPatient Information: Height Weight Primary Care Physician:Smoking Status:Current SmokerFormer SmokerNever SmokedSmokeless Tobacco UserWomen of childbearing age:Are you currently pregnant or nursing?YesNoSelfFamily Member(s)Digestive SystemBlood / LymphEar / Nose / ThroatAllergies / Immune systemSkinMental / PsychiatricMusculoskeletal (arthritis, joint pain, etc.)Respiratory (asthma, emphysema, etc.)Nervous System (headaches, MS, seizures, etc.)Endocrine (thyroid, diabetes, etc.)Cardiovascular (cholesterol, high blood pressure, etc.)Genitourinary (kidney, bladder, etc.)Please describe any conditions marked above, and the how the family member is related to you, if applicable:Please list all medications: Please list all medication allergies: Thank you and welcome to our practice!
