WELCOME FORM

WELCOME FORM
Name*

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email:
example@example.com
Date Of Birth
Age
Gender

MaleFemale
Occupation
Employer
Vision Insurance
Insured Name
Insured Date Of Birth
Insured Social Security
How did you hear about us?

Internet / Social MediaDrive ByFriend /Family ReferralInsuranceOther
If Friend/Family referral, whom may we thank for the referral?
Date of last eye exam ( If known )

MonthDayYear
Date
Location / Name Last Eye Doctor ( If known )
Do you wear glasses?

YesNo
Do you wear contact lenses?

YesNo
If Yes, what brand of contact lens?
Name Of Contacts Lens
What is the reason for today's visit?

Eye examinationContactsGlassesOther
PERSONAL MEDICAL HISTORY - Do YOU have any of the following MEDICAL conditions

High Blood PressureDiabetesThyroid DiseaseHigh CholesterolOther
FAMILY MEDICAL HISTORY - Does any one in your FAMILY have any of the following MEDICAL conditions

High Blood PressureHigh CholesterolDiabetesThyroid DiseaseOther
PERSONAL OCULAR HISTORY - Do YOU have any of the following OCULAR conditions

GlaucomaCataractsEye Injury /SurgeryOther
FAMILY OCULAR HISTORY - Does any one in your FAMILY have any of the following OCULAR conditions

GlaucomaCataractsEye Injury /SurgeryOther
Currently Pregnant

YES
List any medications you are taking:
List any allergies you have:
We are committed to early detection and prevention of eye diseases. We strongly recommend that all of our patients receive DILATION and FUNDUS PHOTOGRAPHY as part of their comprehensive vision examination.
A dilated fundus exam helps us detect diseases within the eye that may not be visible during a basic eye exam and is strongly encouraged if the patient has diabetes, high blood pressure, high prescription, or a family history of eye diseases. The side effects are blurred near vision and light sensitivity for a few hours. Please select:

YES, I want the dilated fundus examNO, I do not want the dilated fundus exam
Fundus Photography involves using an advance Digital Retinal Camera which allows us to take detailed photographs of the back of your eye the retina It captures a clear view of the optic nerve, blood vessels, and macula. This screening is important for detection and monitoring of many eye disease such as glaucoma diabetic eye disease, and macular degeneration. The images will be part of your health record and be used for future comparisons. Digital copies are available upon requests. The cost for this service is $29. Please select:

YES, I want the fundus photographyNO, I do not want the fundus photography
ALL FEES FOR PROFESSIONAL SERVICES ARE NON-REFUNDABLE AND PAYABLE AT TIME OF SERVICE.

I authorize the release of any medical information necessary that will be beneficial to my eye examination. I also authorize payment of medical benefits to my doctor and understand that I am responsible for any charges not covered by my insurance. I have also been presented with the notice of privacy from Precise Eyecare, or one will be provided for me upon request.
Signature.*

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please sign your name inside box
Date

MonthDayYear
Date
Relationship to patient ( If patient is a minor)
type relationship to minor
Please verify that you are human*
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