Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at (817)847-9000. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address

City	St	Zip

Hm Phone
Cell Phone
Wk Phone
Other Phone
Email
Preferred Contact By
DOB (mm/dd/yyyy)
Sex	Female Male
Marital Status
Employment Status	Employed FT Student PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race
Ethnicity
Preferred Language

Who may we thank for referring you to our office?

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	St	Zip
Hm Phone
Wk Phone

General Medical History

Primary physician's name and phone
When was your last physical exam?

Check the box for any conditions that apply:

	You	Mom	Dad	Sib	Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes

If *YOU* are diabetic, when were you diagnosed?		Last A1C level?
Are you Pregnant or Nursing?

List ALL major injuries or surgeries you have had and approx dates:

List any other medical conditions you have had, including non-drug allergies:

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Smoking Status
Alcohol Use
Do you live alone?

Review of Systems

Please list any problems you are currently having anywhere, from head to toe:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Respiratory (e.g., chronic cough, shortness of breath, wheezing)

Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Ocular History

Who was your previous eye doctor?
When was your last eye exam?

Check the box for any conditions that apply:

	You	Mom	Dad	Sib	Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

List any major eye injuries, infections or surgeries and approx dates:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

List any vision complaints you are currently having such as:

blurred vision, headaches, eyestrain, double vision, or losing your place when reading
itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes?
How many hours/day do you typically spend reading books, magazines, etc?

What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glassess?
Are you interested in contacts?
Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?

Patient Signatures

HIPAA Privacy Policy

**View HIPAA Privacy Policy**

Patient Signature: Date:

Acknowledgement of Receipt for HIPAA Compliancy

I acknowledge that I've read a copy of Western Center Eye Care's notice of Privacy Practices.

Patient Signature:
Relationship To Patient:      Date:

Designation of Those Who Can Receive Information About My Care To allow a family member, other relative, or a close personal friend to have access to PHI. I designate the following individuals to have access to information about me that is created by or on behalf of Western Center Eye Care, and that this information can include PHI. I understand that I may revoke this designation at any time by completing a new form; and that this designation will not expire unless and until I actively revoke it. I understand that these individuals will not be able to request a paper or electronic copy of my health records without my having completed an Authorization to Release Medical Information form. I understand that my healthcare treatment or payment, or my enrollment or eligibility for benefits cannot be conditioned on my designating or not designating an individual below.

Name:      Relationship:

Name:      Relationship:

Name:      Relationship:

Insurance Assignment and Release

I certify that I and/or my dependents are covered by insurance
and assign directly to Western Center Eye Care all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submission.

Western Center Eye Care may use my, and/or minor/Child's, healthcare information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services.

Financial Agreement

I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree the parents, guardians, or personal representatives are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges for services or items provided to me, to my minor/child, or to the patient for whom I have legal responsibility. I understand that filing a claim with my insurance company does not relieve me from my responsibility for the payment of all charges.

Patient Signature:
Relationship To Patient: Date:

Patient Authorization

Patient Signature:
Relationship To Patient: Date:

** If you have any insurance, we will be glad to help you file for any benefits to which you are entitled. However, it remains the responsibility of the individual patient to settle his/her account promptly.**

Insurance Guidelines and Policies

WELL VISION EXAMS

A Well Vision exam (also known as Routine Vision) is an exam that is usually performed every year to check the overall health of your eyes and includes refraction (prescription) for eyeglasses. **Please note a contact lens fitting is a separate exam, performed yearly, that may or may not be covered by your vision insurance. Examples of vision insurance: Eyemed, VSP, Block Vision and Spectera.

**This type of exam does NOT include ocular related diseases/conditions or complaints such as diabetes, headaches, eye pain, dryness, glaucoma, cataracts, floaters, etc See Medical Exams below

MEDICAL EXAMS

A medical exam is one that evaluates or maintains the condition of an ocular disease or problem. There are also instances where your medical condition will have an effect on your ocular health such as high blood pressure, diabetes or taking certain medications. In these instances we will bill your medical insurance and collect any necessary co-pays and/or deductibles.

IF YOU PRESENT WITH BOTH A VISION COMPLAINT AND A MEDICAL COMPLAINT, WE RESERVE THE RIGHT TO BILL THE APPROPRIATE INSURANCE. BY FEDERAL LAW WE ARE REQUIRED TO COLLECT ALL CO-PAYMENTS. YOUR CHIEF COMPLAINT WILL DICTATE WHICH INSURANCE WE WILL FILE.

If for some reason we are unable to obtain an authorization before your services are rendered, you will be required to file your insurance, whether medical or vision. You also will be responsible for all professional services provided and materials purchased.

THANK YOU

Patient Siganture:

Patient Information and Medical History Form