St. Lucie Eye Care Patient Intake Form

Patient Intake Form
Appointment Date

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Date
Last 4 of your SSN*
Sex*

FemaleMale
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Type a label Employer/Occupation .
Are you the insurance policy holder?*
Responsible Person / Insurance Policy Holder
MEDICAL INSURANCE PROVIDER
Medical Insurance Provider*
Medical Insurance Card (Front)
Medical Insurance Card (Back)
VISION INSURANCE PROVIDER
Vision Insurance Provider*
Vision Insurance Card (Front)
Vision Insurance Card (Back)
Check all that apply to you*

Eye Drop UsePregnant NowAsthmaEye SurgeryAllergiesCOPDEye InjuryHeadacheAcid RefluxEye Infection/DiseaseMigraineColon DiseaseDry EyesSeizuresKidneys/Bladder ProblemsItchy EyesCancer on FaceDialysisLazy Eye (Amblyopia)Acne RosaceaArthritisGlaucomaHigh Blood PressureRheumatoid FactorMacular DegenerationHigh CholesterolCancerCataractsHeart ProblemsStroke HistoryThyroidPhyschiatric IssuesNONEDiabetesOther
Do any of your parents, grandparents, or siblings have any of the following? (Select all that apply)*

CataractsDiabetesRetinal DetachmentMacular DegenerationGlaucomaNONE
List any chronic health problems you may have*
List all major surgeries*
List out all current medication*
List out allergies
Reason for today's visit?*
Exam History
Do you wear glasses? If so, select all that apply.

Full-timeDistanceNear/ReadingSafety
Do you wear contacts?

YesNoOther
If so, please select wear schedule:

DailyWeeklyBiweeklyMonthly
Contact Lenses
Are you interested in contacts?*

YesNo
Please select the option that apply regarding your smoking habits

None0 -1 package a day1 - 2 packages a day2+ packages a day
Do you consume alcohol?

YesNo
Average hour of sleep per week?
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I directly assign to the doctor all insurance benefits, if any, otherwise payable to me for services rendered.I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The doctor may use my health care information and may disclose such information to the insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Signature*

Clear
Date*

MonthDayYear
Date
Print*

First NameLast Name
How did you hear about our office?*
Should be Empty:

Patient Intake Form

MEDICAL INSURANCE PROVIDER

VISION INSURANCE PROVIDER