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

Occupation

Employer

Vision Insurance

Insured Name

Insured Date Of Birth

Insured Social Security

How did you hear about us?

If Friend/Family referral, whom may we thank for the referral?

Date of last eye exam ( If known )

Date

Location / Name Last Eye Doctor ( If known )

Do you wear glasses?

Do you wear contact lenses?

If Yes, what brand of contact lens?

Name Of Contacts Lens

What is the reason for today's visit?

Other

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

FAMILY MEDICAL HISTORY - Does any one in your FAMILY have any of the following MEDICAL conditions

PERSONAL OCULAR HISTORY - Do YOU have any of the following OCULAR conditions

Other

FAMILY OCULAR HISTORY - Does any one in your FAMILY have any of the following OCULAR conditions

Other

Currently Pregnant

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:

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:

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.

please sign your name inside box

Date

Relationship to patient ( If patient is a minor)

type relationship to minor

Please verify that you are human