lapalmaeye.com - New Patient Form

New Patient Form

Information gathered is for insurance and communication purposes only. It will never be shared or sold.
Name*

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Birth Date

MonthDayYear
Date
Marital Status

MarriedSingle
Sex

MF
SS#
Address

Street Address

Street Address Line 2

CityState

Zip Code
Responsible Party

SelfOther
Other
Primary Insurance
ID#
GRP#
PPOHMOMedi-CalMedicare
Secondary Insurance
ID#
GRP#
PPOHMOMedi-CalMedicare
Vision Plan

VSPEyemedSpecteraDavisMESOther
I authorize payment of medical or vision benefits and release of medical information to Ilan Hartstein, M.D inc.. I agree to pay any amount approved but not paid for by my insurance eg: deductible, co-insurance, copay or non covered services. I acknowledge that I have received a copy of the notice of Privacy Practice.
Signature
Date

MonthDayYear
Date
Comprehensive History
What is your chief complaint / reason for visit?
Previous Eye History

None
Previous Medical History

None
Allergies to medications

YesNo
If yes, please list allergies:
Current medications or drops

None
Medical History / System Review
Do you have or have you had any of these conditions? Please check only those that apply

AsthmaStrokeThyroidCholesterolHigh Blood PressureDiabetesCancerNone of the aboveOther
Family History

GlaucomaBlindnessRetinal DiseaseDiabetesNone
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Form