New Patient Welcome Form

New Patient Welcome Form
Welcome to Griswold Eye Care! We appreciate your time in answering the questions on this form. Your overall health relates to your eye health so each section is important. Thank you!
Mr.   Mrs.   Ms.
Other:
Preferred Pronouns:He/Him   She/Her   They/Them
Name

First NameLast Name
Preferred Name First Name
Date of birth: Date SSN (if applicable): Type a label
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Texting? Yes No
Email
example@example.com
EMERGENCY CONTACT
First Name Last Name Phone: Area Code Phone Number
Relationship: Type a label
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
VISION INSURANCE(if applicable)

ID#:
Primary Insured:   First Name   Last Name
Relationship to Insured:
Date of Birth
MEDICAL INSURANCE (if applicable)

ID#:
Primary Insured:   First Name   Last Name
Relationship to Insured:
Date of Birth
Other Insurance: Type a label
ID#: Type a label
I have provided any and all insurance information. If any is withheld at time of service, I acknowledge I am responsible for the usual and customary charges for services rendered
Signature*

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Date

MonthDayYear
Date
I have read and agree to the Office Policies agreement set by Griswold Eye Care, PLLC.
Signature

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HIPAA POLICY: Please read carefully. Signature Required.I agree to allow my medical information be shared with my insurance company for the sole purpose of billing and to any healthcare provider necessary for continuity of care. I acknowledge that I am aware that Griswold Eye Care has a notice of privacy practices available to me at all times during normal business hours. I fully understand that I am protected under HIPAA and will be required to sign a release for any and all medical records.
Signature*

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Date

MonthDayYear
Date
Primary Care Physician   First Name   Last Name
Clinic Name:   Type a label
Other Clinic or Dr. to send exam notes to:   Type a label
PREFERRED PHARMACY
Pharmacy Name: Type a label Town/City: Type a label
HEALTH HISTORY
Main Reason for Today's Exam:      Last Eye Exam:   Date
Last Physical Exam:   Date
Are you pregnant or nursing?      YES   NO
Past or Current Head/Eye Injuries or Surgeries:
Any and ALL Medications (please attach list if needed) If none please write NONE:   *
Current Eye Drops:
Allergies/Sensitivities to Medications:
Other Allergies:
SOCIAL HISTORY
Current Occupation:      Years:
Employer:
Do you Drive?    YES   NO        Drink Alcohol?      YES   NO
Smoke Cigarettes?         YES   NO
GLASSES HISTORY
Have you ever worn glasses?     YES   NO
Do you currently wear glasses?         YES   NO
If yes, what type of glasses worn?   Distance   Reading   Bifocals (lined)   Progressives
Have you ever worn contact lenses?      YES   NO
Do you currently wear contact lenses?   YES   NO
If yes, what brand/type of contact lenses?
EYE HISTORY
Do you have.......
Blurry vision at distance without glasses?    YES   NO*
Blurry vision at near without glasses?            YES   NO*
Floaters?            YES   NO
Eye pain?     YES   NO
Dry, gritty or burning sensation of the eye?   YES   NO
Amlyopia?            YES   NO
Macular Degeneration?     YES   NO
History of eye surgery?   YES   NO
History of retinal detachment?            YES   NO
History of ocular trauma?     YES   NO
Glaucoma?      YES   NO
Color Blindness?    YES   NO
MEDICAL HISTORY
Have you been diagnosed with.....
High blood pressure?        YES   NO
Diabetes?           YES   NO
High cholesterol?        YES   NO
HIV or AIDS?         YES   NO
Arthritis?         YES   NO
Asthma?           YES   NO
COPD or lung problems?   YES   NO
Thyroid Condition?            YES   NO
History of stroke?         YES   NO
Use a CPAP machine?    YES   NO
Other? Please list
FAMILY HISTORY
Unknown         If Yes, Who?
Macular Degeneration   YES   NO
Glaucoma      YES   NO
Color Blindness     YES   NO
Blindness   YES   NO
Diabetes    YES   NO
Cancer      YES   NO
High Blood Pressure    YES   NO
Thyroid     YES   NO
Other? Please list
Any additional information you would like us to know: Type a label
Should be Empty:

New Patient Welcome Form

Welcome to Griswold Eye Care! We appreciate your time in answering the questions on this form. Your overall health relates to your eye health so each section is important. Thank you!

I have provided any and all insurance information. If any is withheld at time of service, I acknowledge I am responsible for the usual and customary charges for services rendered