Patient information

First name

*This field is required

Last name

*This field is required

Preferred Name

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

*This field is required

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Height:

Weight:

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

Eye History

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Only answer the following if you currently wear glasses:

I currently wear glasses:
Full-time Part-time
(If part-time, how often/when?)

Only answer the following if you currently wear contacts:

I currently wear contacts:
Full-time Part-time
(If part-time, how often/when?)

Current Brand:

My contacts are: Soft Rigid Gas Permeable Scleral

Are you currently comfortable in your contacts? Yes No

When do you typically switch into a new pair of contacts?

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Please list any eye drops you currently use(OTC and Rx) How often do you use them?

Do you have a history of / or currently suffer from:

Blindness

Yes No

Eye Turn

Yes No

Lazy Eye

Yes No

Keratoconus

Yes No

Glaucoma

Yes No

Cataracts

Yes No

Macular Degeneration

Yes No

Retinal Detachment

Yes No

Headaches

Yes No

Blurred Vision

Yes No

Double Vision

Yes No

Tired/Painful Eyes

Yes No

Halos Around Lights

Yes No

Light Sensitivity

Yes No

Frequent Styes

Yes No

Redness/Irritation

Yes No

Itching

Yes No

Burning

Yes No

Tearing

Yes No

Dryness

Yes No

Sandy/Gritty

Yes No

Flashing Lights

Yes No

Floaters

Yes No

Have you had any eye injuries? No
If yes, please detail:

Have you had any eye surgeries? No
If yes, please detail:

Medical History

Primary Care Physician's Name

When was your last physical?

Pharmacy Name

Pharmacy Phone Number

Medications No Medications

Drug allergies No Allergies

Are you pregnant or nursing?
Yes No

If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas?

Diabetes

Yes No

If yes, how many years?

Herpes/Shingles

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Heart Disease

Yes No

Kidney Disease

Yes No

Thyroid Problems

Yes No

Gastrointestinal

Yes No

Neurological (Brain)

Yes No

Migraines

Yes No

Stroke

Yes No

Skin Condition

Yes No

Arthritis

Yes No

Asthma/Lung Problems

Yes No

Cancer

Yes No

Anemia

Yes No

Multiple Sclerosis

Yes No

Allergies/Hay Fever

Yes No

HIV

Yes No

Hepatitis

Yes No

Emphysema

Yes No

How often do you smoke/use tobacco products?

How often do you consume alcohol? (Be honest!)

Family History

Any history of the following in any family members? (If Yes, please mention relationship to patient in text

My Family history is unknown/I was adopted

Poor Vision

No Yes

Cancer

No Yes

Blindness

No Yes

Diabetes

No Yes

Eye Turn

No Yes

High Blood Pressure

No Yes

Lazy Eye

No Yes

Stroke

No Yes

Glaucoma

No Yes

Thyroid Disease

No Yes

Cataracts

No Yes

Retinal Detachment/Disease

No Yes

Macular Degeneration

No Yes

How did you hear about Somerset Eye Care?

If applicable, please enter the name of the person or detail how you were referred to our office

RETINA PHOTOGRAPHS

Our doctors strongly recommend digital retinal photography as part of the yearly eye exam for all patients. These eye wellness photographs are a permanent record in your medical file that allow the doctors to better diagnose and document many eye conditions year after year. Most insurances do not cover the fee for the procedure ($39). If you would like additional information before having the photographs taken, please notify the Technician or Doctor.

Additional Information

Most insurance policies pay only a portion of your total charges. If you have questions about your coverage, please contact your representative. It is your responsibility to verify coverage for the services provided. We can not guarantee the accuracy of benefit information given to us by insurance companies.

I understand that the financial responsibility for my account is mine, and not the insurance company's. I understand that any balances not covered by insurance are my sole responsibility and that if my account is sent to a collection agency due to unpaid balances, then a $30 collection fee will be added to my account.

I authorize the release of any medical or other information necessary to process insurance claims. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the physician for services rendered. I have read and agree to the Notice of Privacy Practices for Somerset Eye Care.

I have read and agree to the above statement.

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