foxeyecare.com - Patient Intake Revised 2023

Patient Intake Form
Location*
Crabtree Valley Mall, Raleigh

4325 Glenwood Ave.
Raleigh, NC 27612
Located next to Lenscrafters
Berkeley Mall, Goldsboro

611A N Berkley Blvd, Berkeley Mall
Goldsboro, NC 27534
Located next to Lenscrafters
Friendly Shopping Center, Greensboro

642 Friendly Center Road
Greensboro, NC 27408
Located next to Lenscrafters
Four Seasons Town Center, Greensboro

330 Four Seasons Town Center
Greensboro, NC 27407
Located next to Lenscrafters
Hanes Mall, Winston-Salem

3320 Silas Creek Pkwy, Suite 300
Winston Salem, NC 27103
Located next to Lenscrafters
Patient Information

If you arrive with a medical condition, we may file with your major medical plan rather than your vision plan.
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell#*
Please enter a valid phone number.
Home/Alt#
Please enter a valid phone number.
SS #*
Sex*
Email: *
example@example.com
Employer
Occupation
Hobbies
Parent/Guardian/Emergency Contact*
Phone#*
Please enter a valid phone number.
* Children ages 15 and under must be accompanied by a parent/guradian. Children 16-18 must have written consent from their parent/guardian.
Insurance Information

(Major Medical)
Financially responsible party:*
Insurance Co*
Member # *
Group #*
Primary Insured's Name*
Insured's DOB*

MonthDayYear
Date
Insured's SS#*
Insurance Information

(Vision or Secondary)
Insurance Co
Member #
Group #
Primary Insured's Name
Insured's DOB

MonthDayYear
Date
Insured's SS#
Medical and Ocular History
Date of last eye exam*

MonthDayYear
Date
Date of last medical exam *

MonthDayYear
Date
Family Doctor*
How many hours a day do you spend on a device?*
Do you wear glasses?*

YesNo
Are you interested in refractive surgery?*

YesNo
Do you wear contact lenses?*

YesNo
Brand
Are you interested in contact lenses?*

YesNo
Allergies*

YesNo
Explain
Major Surgeries*
Medications you are currently taking (including OTC)*
Do you or any family member have a history of the following:

Eyes*

	NO	YES	If Yes, Self/Family
Blindness
Blurred vision
Burning/Itching
Cataracts
Chronic eye infections
Crossed eye
Double Vision
Dry eyes
Excessive Tearing
Eye Allergies
Eye Pain/Soreness
Flashes/Floaters
Glare/Light sensitivity
Glaucoma
Halos
Loss of vision
Macular Degeneration
Mucous discharge
Red eyes
Retinal detachment
Retinal Problems

Other*

	NO	YES	If Yes, Self/Family
Cancer
Diabetes
Headaches
Heart Diseases
High Blood Pressure

Medical History Required by your Insurance Carrier(s)

Musculoskeletal *

	NO	YES	If Yes, Self/Family
Arthritis
Joint pain

Allergic/Immunologic *

	NO	YES	If Yes, Self/Family
Hay Fever
Medicine Allergies
Systemic Allergies

Genitourinary *

	NO	YES	If Yes, Self/Family
Kidneys
Bladder

Respiratory *

	NO	YES	If Yes, Self/Family
Chronic Bronchitis
Emphysema

Hematologic/Lymphatic *

	NO	YES	If Yes, Self/Family
Anemia
Bleeding Problems
Swelling

Cardiovascular *

	NO	YES	If Yes, Self/Family
Heart Problems
Vascular disease

Neurological *

	NO	YES	If Yes, Self/Family
Seizures
Headache(s)
Other

Ears, Nose, Mouth, Throat *

	NO	YES	If Yes, Self/Family
Sinus problems
Chronic cough
Dry mouth/Throat
Chronic ear infections
Psychiatric

Gastrointestinal *

	NO	YES	If Yes, Self/Family
Ulcers
Other

Endocrine *

	NO	YES	If Yes, Self/Family
Thyroid problems
Other glands

Constitutional *

	NO	YES	If Yes, Self/Family
Fever
Weight changes

Have you ever been exposed to or infected with: Gonorrhea, Hepatitis, HIV, Syphilis, Chlamydia*

YesNo
Comments on any Medical Condition:*
Do you use smoke/drink?*

YesNo
If yes, type, amount and how long?
Dilating the pupil with eye drops helps the doctor examine the inside of the eye more thoroughly. A large area of the retina (the lining inside the eye) cannot be seen without a dilated eye exam. Many eye diseases cannot be detected without this important procedure. This procedure is included in your eye exam. Eye drops are used to make the pupils larger. These drops make your vision blurry and more sensitive to light for usually 2 to 3 hours. We use a weaker drop, so most patients are able to drive comfortably, however, driving and/or reading can be difficult for some. Disposable sunglasses are provided to you after the dilation. The doctor may recommend this test to you.
Please check the appropriate line below:*

Yes, I am prepared to have my pupils dilated if necessary and I understand that my vision will be blurry.No, I do not wish to have my pupils dilated.I would like to discuss this further with the doctor.
Have you ever been dilated before?*

YesNo
If so, were there any rare medical complications outside of glare and short term visual changed? *

YesNo
I hereby authorize FECG to release any medical or incidental information that may be necessary for medical benefit or in processing applications for submissions to my insurance company. I understand I am responsible for payment of all charges. As a courtsey, my insurance may be billed for me. It is my responsibility to pay any deductible, copay, or any balance not paid by my inurance carrier. I understand professional fees are non-refundable.

VERIFICATION OF BENEFITS IS NOT A GUARANTEE OF PAYMENT.
Signature: *

Clear
Date:*

MonthDayYear
Date
Payment Policy:

Initial* Financial Responsibility: I acknowledge I have read and signed FECG's Financial Responsibility Form
Initial* HIPAA Receipt: I acknowledge I have read/received FECG's Notice of Privacy Practices
Signed and agreed to this date:*
Patient Name *
Signature*

Clear
Should be Empty:

Patient Intake Form

Patient Information

Insurance Information

Insurance Information

Medical and Ocular History

Medical History Required by your Insurance Carrier(s)