malonevision.com - New Patient Form

Patient Information
Legal Name:

First NameLast Name
Preferred Name:
DOB:

MonthDayYear
Date
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Other:
Please enter a valid phone number.
Email:
example@example.com
Preferred Method of Contact:

Cell PhoneHome PhoneText MessageEmail
Occupation:
Employer:
How did you hear about us?
Do you wear glasses?
Do you wear contacts?
If so, what brand?
Please check any condition(s) that apply to YOU:

DiabetesCataractsGlaucomaMacular DegenerationEye SurgeryEye InjuryPregnantThyroidHigh Blood PressureHeart ConditionsFrequent HeadachesTurned or Lazy Eye
Current (everyday) SmokerCurrent (someday) SmokerFormer SmokerNever Smoker
Primary Care Physician:
Preferred Hospital:
Preferred Pharmacy:
Please note any family history (parents, grandparents, siblings and/or children; maternal or paternal; living or deceased) for the following conditions:

DISEASE/CONDITION

	YES	RELATIONSHIP TO YOU
Diabetes
Cataracts
Glaucoma
Macular Degeneration
Eye Surgery
Eye Injury
Thyroid
High Blood Pressure
Heart Conditions
Frequent Headaches
Turned or Lazy Eye

Any other conditions:
Please list any known drug allergies:
Please list your current prescribed medications:
The Commission to End Health Care Disparities recommends that all practices collect certain basic demographic information on each patient served to help monitor quality of care. To the best of your ability please complete the following:
Preferred Language:

EnglishSpanishOther
Race:

WhiteBlack or African AmericanWhiteBlack or African American
Ethnicity:

Hispanic or LatinoNon- Hispanic or Latino
Wellness Retinal Scan

A Wellness Scan is a non-invasive scan of the eye that can assist in the early detection of Glaucoma, Macular Degeneration and Neurological disorders (Aneurysms and Optic Nerve Disease).

The recommended guideline for a Wellness Screening is any patients age 13 years and older every year with your regular exam
**Please note, insurance does not cover this test, patients are responsible for the charge.**

YES, I do want the Wellness Retinal Scan Fee $45NO, I do not want the Wellness Retinal Screening
Please Read:

Dr. Malone is a Medicare provider. Medicare will pay for medical services if there is a medical eye problem, such as cataracts, glaucoma, or diabetes. Medicare does not pay for a routine eye exam or screenings. We file Medicare unassigned which means we require payment on the day services are rendered. Any reimbursements will be sent to you directly from Medicare if you have met your deductible. If you have not met your deductible, the amount will be applied toward your deductible.

The only private insurances accepted in our office are BCBS PPO, Humana, Eyemed, Aetna, and Eyetopia. We do require private insurances be pre-authorized before the day of the visit in order to inform you of any out of pocket fees since payment is required the day services are rendered. If you have another type of private insurance coverage for eye care, we will be happy to supply you with an itemized superbill for you to submit your claim.
Patient’s Signature:

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Date:

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If you are signing as personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor.
Representative’s Signature:

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Patient Information