drbechererandassociates.com - Welcome Form

WELCOME TO OUR OFFICE
Title

Other
Nickname
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First Middle Last
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (home)
Please enter a valid phone number.Format: (000) 000-0000.
Phone (work)
Please enter a valid phone number.Format: (000) 000-0000.
Extension
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we call your cell phone?
E-mail
example@example.com
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Hobbies
Spouse
Is your spouse our patient?
Who recommended us?
If child: Parent or Guardian
Occupation
Employer
Social Security #
Medicare #
Will you be paying for today's services by:

Other
PLEASE NOTE:
We require payment when services are rendered. If you are using any kind of insurance, it is the policy owner's responsibility to know what your policy covers. A deposit is required on all materials with the balance paid in full upon delivery or shipping. Any bill which is 30 days overdue will be charged 1.5% per month service charge. In the event there is a default of payment, patient agrees to pay expenses of collection, including but not limited to attorney fees, court cost or collection company fees. If any kind of insurance is used and there are additional fees or charges owed, one billing statement will be sent at no charge. Each additional statement will be $6.00.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Personal
Do you wear glasses?
Contact Lenses?
Type
Are you interested in contact lenses?
Are you interested in refractive surgery?
Date of last eye exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Doctors Name
Were your eyes dilated?
If YES: any complications?
What was prescribed?

MEDICAL INFORMATION
Many conditions and medications affect your eyes and vision. Please list ALL medications and what they are for:
Review of systems: Please check if any apply (& add an "R" for a blood relative).

Allergic/Immunologic

Rows	Check	Blood Relative
drug allergy
environmental allergy
rheumatoid arthritis
lupus
other

If drug allergy, please list:

Gastrointestinal

Rows	Check	Blood Relative
Crohn's
colitis
ulcer
digestive
other

Skin

Rows	Check	Blood Relative
eczema
rosacea
psoriasis
dry
other

Psychiatric

Rows	Check	Blood Relative
depression
panic disorder
schizophrenia
other

Heart

Rows	Check	Blood Relative
heart disease
hypertension
stroke
vascular disease

Endocrine

Rows	Check	Blood Relative
diabetes (insulin)
diabetes (non-insulin)
thyroid problem
hormone changes

Genitourinary

Rows	Check	Blood Relative
STD
herpes
other

Respiratory

Rows	Check	Blood Relative
asthma
bronchitis
emphysema
cigarettes

If you smoke cigarettes, please specify how much:

Neurologic

Rows	Check	Blood Relative
multiple sclerosis
epilepsy
other

Muscles/Skeletal

Rows	Check	Blood Relative
fibromyalgia
muscular dystrophy
osteoarthritis
ankylosing spondylitis
other

Blood/Lymphatic

Rows	Check	Blood Relative
anemia
leukemia
blood loss

Constitutional

Rows	Check	Blood Relative
developmental disability
weight loss
fever
fatigue
trauma
other

Eyes

Rows	Check	Blood Relative
cataract
glaucoma
macular degeneration
floaters/flashes
lazy eye
glare
color blindness
eye pain
dry eye
retinal problems
blurred vision
temporary vision loss

LIST ALL EYE SURGERIES & INJURIES, INCLUDING DATES:
Should be Empty: