Tucson Eye Physicians New Patient

TUCSON EYE PHYSICIANS P.L.L.C.
WHO RECOMMENDED YOU TO OUR OFFICE?
DO YOU SEE AN OPTOMETRIST FOR OTHER EYE CARE?*
IF SO WHOM?
DO YOU HAVE A PHARMACY YOU USE?*
IF YES, PLEASE LIST THE NAME AND ADDRESS OR CROSS STREETS CLOSEST TO THAT PHARMACY:
PATIENT'S NAME:*

First NameMiddle InitialLast Name
ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DAYTIME PHONE #*
Please enter a valid phone number.Format: (000) 000-0000.
SECONDARY PHONE #:
Please enter a valid phone number.Format: (000) 000-0000.
E-MAIL:*
example@example.com
SEND MY BILLS TO THE ABOVE ADDRESS:*
IF OTHER, PLEASE LIST THE ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH:*

MonthDayYear
Date
AGE:
MALEFEMALEOTHER
SSN:
SINGLEMARRIEDWIDOWEDDIVORCEDSEPARATED
WHITEBLACK OR AFRICANHISPANICASIANOTHER
ENGLISHSPANISHOTHER
IF OTHER, WHICH LANGUAGE DO YOU PREFER:
PRIMARY CARE PHYSICIAN:*
SPOUSE NAME:
PERSON TO CONTACT IN CASE OF AN EMERGENCY:*
EMERGENCY PHONE #:*
Format: (000) 000-0000.
INSURANCE INFORMATION
ENTER YOUR PRIMARY AND SECONDARY (IF APPLICABLE) INSURANCE BELOW:
YESNO
PRIMARYSECONDARY
PRIMARY INSURANCE:*
ID#:*
GROUP#:*
SECONDARY INSURANCE:
ID#:
GROUP#:
MEDICAL INFORMATION
THE COMPLETION OF THIS FORM ENABLES US TO PROVIDE YOU WITH A HIGHER QUALITY OF MEDICAL CARE.
CATARACTSCATARACT SURGERYMACULAR DEGENERATIONGLAUCOMACONTACT LENS WEARERFLASHES OF LIGHTFLOATERS OR SPOTSWATERING EYESGLARE AT NIGHTRED EYESEYE INJURYDRY EYESMATTER/GOOPEYE PAINBURNING SENSATIONEYE STRAINDOUBLE VISIONSENSITIVITY TO LIGHTITCHINGRKPRKLASIKOTHER
IF OTHER, PLEASE LIST
NONECANCERARTHRITISASTHMAANXIETYCONGESTIVE HEART FAILURECOPDDEMENTIADEPRESSIONLUPUSGERDHEART ATTACKOSTEOPOROSISDIABETES TYPE IDIABETES TYPE IIHIGH CHOLESTEROLHIVHIGH BLOOD PRESSUREHYPERTHYROIDISMTHYROID DISEASEHYPOTHYROIDISMHEPATITIS A, B, CKIDNEY DISEASERHEUMATOID ARTHRITISMEMORY LOSSMENTAL ILLNESSNEUROLOGICAL DISORDERSTROKEPROSTRATE PROBLEMS
DO YOU SEE AN ENDOCRINOLOGIST OR RHEUMATOLOGIST?*
IF YES, PLEASE LIST THE DOCTORS NAME:

FAMILY HISTORY: SELECT ONLY IF IT RUNS IN YOUR FAMILY

Rows	FATHER	MOTHER	GRANDPARENTS
GLAUCOMA
MACULAR DEGENERATION
DIABETES
CANCER

HABITS:
YESNO
YESNO
YESNO
YESNO
CODEINE:LATEX:ASPIRIN:MORPHINE:PENICILLIN:IODINE DYE:SULFA:NO KNOWN MEDICATION ALLERGIESOTHER
IF OTHER, PLEASE LIST
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MEDICATIONS: PLEASE LIST ANY MEDICATIONS AND DOSAGE
1.
2.
3.
4.
5.
6.
7.
8
9.
10.
11.
12.
13.
14.
15.
RELEASE OF MEDICAL INFORMATION
I, AUTHORIZE TUCSON EYE PHYSICIANS TO NOTIFY ME OF MY UPCOMING APPOINTMENTS:*
Name of patient
YESNO
YESNO
PATIENT INITIALS:*
THE ABOVE INFORMATION WILL ASSIST THIS OFFICE IN CONTACTING YOU WITH ANY DIAGNOSTIC TESTS, UPCOMING APPOINTMENTS AND/OR RESULTS; IT WILL ALSO ASSIST IN YOUR MEDICAL CARE. THIS INFORMATION WILL BE MAINTAINED WITH YOUR MEDICAL RECORDS. THIS WILL REMAIN IN EFFECT UNTIL YOU NOTIFY US OF ANY CHANGES.
PATIENT PRINTED NAME:*
Patient Representative
Relationship to the patient
LIFESTYLE QUESTIONNAIRE
PLEASE SELECT THE FOLLOWING ACTIVITIES THAT YOU DO ON A REGULAR BASIS THAT HAVE BEEN AFFECTED BY YOUR CURRENT VISION.
DRIVING - DAYTIMEDRIVING - NIGHTTIMEGOLFING/OTHER SPORTS
SEEING CAR DASHBOARDUSING TABLETPLAYING CARDSUSING COMPUTER
READING BOOKS/NEWSPAPERUSING CELLPHONESEWING
BRIGHT DAYLIGHTNIGHTTIME STREETS/HEADLIGHTSREADING STREET SIGNS DAY OR NIGHT
EASYGOINGFLEXIBLEORGANIZER/PLANNERPERFECTIONIST
BY SIGNING THIS FORM, I AM CONSENTING TO TUCSON EYE PHYSICIAN'S USE AND DISCLOSURE OF MY PROTECTED HEALTH CARE INFORMATION FOR THE PURPOSE OF CARRYING OUT TREATMENT, FILING INSURANCE FOR PAYMENT AND HEALTHCARE OPERATIONS. I HAVE READ, BEEN OFFERED AND/OR PROVIDED A COPY OF TUCSON EYE PHYSICIANS NOTICE OF PRIVACY PRACTICES.

I HEREBY AUTHORIZE AND DIRECT PAYMENT TO TUCSON EYE PHYSICIANS, FOR ANY SURGICAL AND/OR MEDICAL BENEFITS, OTHERWISE PAYABLE TO ME UNDER TERMS OF MY INSURANCE. I ACKNOWLEDGE THAT I AM FINANCIALLY RESPONSIBLE FOR NON-COVERED SERVICES OR EXPENSES INCLUDING REFRACTIONS. I HEREBY AUTHORIZE PHOTO COPIES OF THIS FORM TO BE VALID AS THE ORIGINAL.

WE WILL BE HAPPY TO DISCUSS ANY QUESTIONS YOU MAY HAVE REGARDING YOUR BILL. PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE.

I HAVE READ AND UNDERSTAND THE ABOVE AGREEMENT.
PATIENT SIGNATURE:*
DATE:*

MonthDayYear
Date
Should be Empty:

TUCSON EYE PHYSICIANS P.L.L.C.

INSURANCE INFORMATION

MEDICAL INFORMATION

HABITS:

RELEASE OF MEDICAL INFORMATION

LIFESTYLE QUESTIONNAIRE