Medical History
PATIENT MEDICAL HISTORY
Please select any problems you may have from the drop downs below.
Please list any Injuries, Surgeries, Hospitalization
Pregnant Or Nursing:
Recent Tetanus Shot:
Medications:
Primary Care Physcian:
Last Visit:
Reason For Visit:
List any Vitamins you take:
Please list any over the Counter medications:
Please list your current Prescription Medications:
No Current Medications
Please list all drug allergies:
No Known Drug Allergies
FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)
Hobbies:
Smoking Status:
Type:
How Long:
Alcohol:
Type:
How Long:
Illegal Drugs:
Type:
How Long:
STD:
PATIENT OCULAR HISTORY
Please select if you have had any of the following:
Please select your current Eye Meds:
Last Eye Doctor:
Last Eye Exam:
FAMILY OCULAR HISTORY
Glaucoma: Crossed / Lazy:
Retinal Detach: Macular Degeneration: Cataracts:
Primary Vision Correction: Planning to get new
glasses?
Back up specs?
Type of CLs worn in past: Wear Time: Cleaner: Disposal:
NOTES:
Preferred Language:
Ethnicity: Race:
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
GENERAL: Fever, weight loss, weight gain, fatigue? |
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EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat |
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CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease |
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RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD |
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GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
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MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
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SKIN: growths, rashes, acne |
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NEUROLOGICAL: Headaches, migraines, seizures |
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PSYCHIATRIC: Depression, Anxiety, Insomnia |
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ENDOCRINE: Thyroid, Diabetes |
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BLOOD/LYMPH: Anemia, cholesterol, bleeding problems |
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ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus,
HIV |
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GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux |
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Submit / Patient Signatures
Click the submit button at the bottom of this tab to complete your forms and submit your information:
Financial Policy and Agreement
ClearView Eyecare, PLLC
Payment is due at time of service, unless prior arrangements have been made. Accepted forms of payment include
cash, check, VISA, Mastercard, Discover and American Express.
Please notify us at least 24 hours in advance if you must change or cancel your appointment. By signing below, I
understand and accept that repeated failure to extend this courtesy will result in an Exam Fee of $200 applied
to my account, payable before any further services will be rendered.
I have read and understand the above financial policy. I agree that I am responsible for all charges incurred on
my account. I also understand that ClearView Eyecare will not share my personal information without my
permission and that I am able to request a complete copy of ClearView Eyecare's Notice of Privacy Practices.
I authorize ClearView Eyecare to contact me via phone, text or e-mail.
Print:
Date:
Signature:
Insurance Assignment and Release:
If we are a participating provider, we will bill your insurance plan. If we bill your insurance, you are
responsible for the co-pay and co-insurance amounts specified by your insurance at the time of service.
I
understand that I will be billed for any services not covered or for any charges deemed patient responsibility
by my insurance plan.
Initial
As a courtesy to you, our staff has done their best to verify your coverage, but as it is the patient's ultimate
responsibility to verify coverage and eligibility, any estimate of patient amounts due are truly estimates.
I understand that it is my responsibility to verify insurance coverage, and any benefit quoted by the staff
at ClearView Eyecare is only an estimate of my coverage.
Initial
Please note that we are providing a service when we file your claim. If a clean claim is not paid after 90 days
from the date of service, we will transfer the balance to you, and you will be responsible for any outstanding
charges on your account.
I understand that I am ultimately responsible for charges even with insurance. Initial
I authorize my insurance benefits to be paid directly to ClearView Eyecare. I understand that I am financially
responsible for non-covered services and materials. Additionally, I authorized the doctor and staff at ClearView
Eyecare to release any and all information required to process my claim.
Print:
Date:
Signature:
HIPAA Compliance Patient Consent Form
To view the HIPPA document please click the link below, once you have read it make sure to come back to this
page and sign below, Thank you!
View HIPAA Compliance Patient Consent
Form
Print:
Date:
Signature: