Patient information

*This field is required

*This field is required

*This field is required

Billing information

If yes, please provide the billing address information below

Primary Vision Insurance

Primary Medical Insurance

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

Chief Complaint

Review of Ocular System

Family Ocular History




Yes    No  
  Blurred Vision Distance
  Blurred Vision Near
  Burning
  Crossed Eyes
  Distorted Vision (Halos)
  Double Vision
  Drooping Eyelid
  Dryness
  Excess Tearing/Watering
  Eye Pain/Soreness
  Flashes
  Floaters/Spots
  Fluctuating Vision
  Foreign Body Sensation
Yes    No  
  Glare/Light Sensitivity
  Headaches
  Eye/Lid Infection
  Itching
  Lazy Eye (Eye Turn)
  Loss of Side Vision
  Loss of Vision
  Migraine
  Mucous Discharge
  Poor Color Vision
  Redness
  Sandy/Gritty Feeling
  Tired Eyes
  Twitching

Demographic Information

Review of Systems

Patient Medical History

Social History

Dry Eye Speed Questionnaire

Dry Eye Disease

Environmental Factors
Systemic Conditions
Systemic Meds
Ocular Meds
Artificial Tears Times/day
Signs
Contact Lenses

Frequency Legend: (rate on a scale of 3: 0 = Never, 1 = Tolerable, 2 = Often, 3 = Consistant)
Severity Legend: (rate on a scale of 4: 0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)

Symptoms
Frequency
of Symptoms
Severity
of Symptoms
Symptoms
at This Visit

Symptoms
Within Past
72 Hours
Symptoms
Within Past
3 Months
Dryness, Grittiness, Scratchiness
Yes No
Yes No
Yes No
Soreness or Irritation
Yes No
Yes No
Yes No
Burning or Watering
Yes No
Yes No
Yes No
Eye Fatigue
Yes No
Yes No
Yes No
Fluctuating Vision
Yes No
Yes No
Yes No

The Insured must please read and sign contract below

In order to control the cost of billing, we ask that the patients portion Is paid at the time services are rendered unless other arrangements are made in advance. We would rather control billing costs than be forced to raise our fees. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts past due are subject to collection. I agree to pay any legal and collection agency fees and interest in the event of delinquency. There will be a service charge on all returned checks. Payment from my insurance is to be paid directly to Priority Eye Care. I understand that if my insurance denies payment, I will be responsible for the amount billed. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.


HIPAA Privacy Policy

Please View HIPPA and Sign below

*Click here to view our HIPAA Privacy Policy*



You're Done! Click the button below to submit your data.