Patient Forms Name* First Last Dr. Mr. Mrs. Miss * Male Female Date of Birth* Social Security #*Marital Status:* Single Married Widowed Divorced Home / Mailing Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Phone:*Cell Phone:*Texting OK?Email Address* EmployerOccupation:Primary Care Physician:Date of Last Physical Exam: Pharmacy:Referred by* Patient Doctor Other Parent / Legal Guardian / Emergency Contact Name:*Primary Phone:*Do you have Medical Insurance?*YesNoPrimary Medical Insurance Name:*Primary Medical Insurance ID #:*Policyholder Name:* First Last Policyholder DOB:* Policyholder Social Security #:*Secondary Medical Insurance?*YesNoSecondary Medical Insurance Name:*Secondary Medical Insurance ID #:*Policyholder Name:* First Last Policyholder DOB:*Policyholder Social Security #:*Do you have a Vision Plan?*YesNoVision Plan Name:*Vision Plan ID #:*Policyholder DOB:*Policyholder Social Security #:*Medical / Ocular HistoryAre you experiencing any blurred vision? Yes No Please Explain:*Any new floaters / flashes of light? Yes No Please Explain:*Any headaches or double vision? Yes No Please Explain:*Are we billing your medical insurance for any medical eye problems or follow up treatment today? Yes No Glasses History:Do you wear glasses? Yes No What difficulties are you having with your current glassesAre there times you'd rather not be wearing your glasses? Yes No Do you have a spare or backup pair of glasses? Yes No What do you use for your everyday sun protection? Polarized Sunglasses UV Blocking Sunglasses Light - Adaptive (transitions) Lenses Contact Lens History:Do you wear contact lenses? Yes No How often do you discard your contact lenses?What type of solution do you use?Rate how your contacts feel immediately after you first put them in:12345678910Indicate the time you generally put your lenses in:Rate how your contacts feel just before you take them out:12345678910Indicate the time you generally take your lenses out:Do you use contact lens rewetting drops? Yes No UntitledIf you're a candidate for full time or occasional wear contact lenses would you like to know? Yes No Many patients struggle with after-dark sight, is that a challenge for you too? Yes No How many hours a day do you focus your eyes on a digital screen, like a computer, iPad, or other electronic device?Favorite sport / hobby your participate in?How would you rate yourself? Easy going Middle of the road Perfectionist Do you use eye drops for lubrication? Yes No If yes, how often?Rate your overall dry eye severity on a day to day basis:12345678910What would you like to see improve with your dry eye:Do you feel your Dry Eye is chronic? Yes No How many Dry Eye medications / drops are you currently using? 0 1-3 4-6 7 more Have you ever been told you have Blepharitis? Yes No Report the frequency of your symptoms using the rating list below:0=Never1=Sometimes2=Often3=ConstantDryness / Grittiness / ScratchinessSoreness or IrritationBurning or WateringEye FatigueFluctuating VisionReport the severity of your symptoms using the rating list below:0=No Problems1=Tolerable2=Bothersome3=IntolerableDryness / Grittiness / ScratchinessSoreness or IrritationBurning or WateringEye FatigueFluctuating VisionHave you experienced these symptoms: Today Within the past 72 Hrs Withing the past 3 Months Are you a: Current Smoker Former Smoker Never Smoker Are you currently: Pregnant / Nursing On Blood Thinner Have a Pace Maker Review of Symptoms:Please select if you have any of the following:Neurological: Headaches Migraines Dizziness / Lightheadedness Seizures Numbness / Tingling Dry Throat / Mouth Respiratory: Asthma Chronic Bronchitis Emphysema Endocrine: Hypothyroid Hyperthyroid Diabetes Ears, Nose, Throat, Mouth: Allergies / Hay Fever Sinus Congestion Runny Nose Post Nasal Drip Chronic Cough Lymphatic / Hematologic: Anemia HIV / AIDS Vascular/ Cadiovascular: Heart / Chest Pain High Blood Pressure Vascular Disease Constitutional: Fever Recent Weight Loss / Gain Cancer Allergic / Immunologic: Eczema Immunologic Disease Bones / Joints / Muscles: Rhematoid Arthritis Muscle Pain / Weakness Joint Pain / Weakness Please list any major surgeries:Please list all daily medicaitons (or bring list)Family History: Macular Degeneration Hypertension Diabetes Glaucoma AUTHORIZATION TO RELEASE HEALTH INFORMATION & ASSIGN BENEFIT By submitting my insurance information I am authorizing the release of all necessary Protected Health Information & assign all medical & vision benefits to Advanced Eyecare Center. I also request that payment of authorized Medicare (if applicable) benefits be made on my behalf to Advanced Eyecare Center for any services furnished to me by Advanced Eyecare Center. I authorize any holder of medical information related to me to be released to the Centers of Medicare & Medicaid Services (CMS) & it's agents, any information needed to determine these benefits or the benefits payable to related services. I understand that I request that payments be made & I authorize release of medical information necessary to pay the claim. In Medicare assigned cases, the supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for deductible, copay and non-covered services. Copay & deductible are based upon the charge determination of the Medicare carrier. I understand that I am ultimately responsible for any bill incurred in this office. Should this account become delinquent, I will be responsible for any & all legal fees, court costs, & collection charges. There will be a service charge for each returned check. This authorization and assignment will remain in effect until revoked by me in writing. A photocopy of this authorization and assignment is to be considered as valid as the original. I request that you file my insurance and I have agreed to and completed all of the conditions listed above. I accept financial responsibility for all charges. I have read and understood this information and have submitted by insurance information voluntarily. Advanced Eyecare Center's Financial Policies: Proof of Insurance: Providing quality medical care is our primary goal. We participate with most insurance programs as a service to you. You, the patient, have the ultimate financial responsibility for services rendered. If you do not provide proof of valid insurance at the time of service, you will be responsible for all fees upon checkout. Coverage And Benefits: Most medical insurance companies do not cover annual vision exams. Some insurance plans offer routine coverage, if you have questions regarding your coverage, please direct them to your employer or your insurer's representative. It is your responsibility to inform us of any secondary benefits of special requirements, such as Worker's Compensation, or you will be financially responsible for services rendered. Please provide proof of any medical and vision coverage. Payment is Due When Services are Rendered: You are responsible for all co-pays and deductibles required by your insurance contract. Co-Pays or Co-Insurance need to be paid the day services are rendered. Any non-covered services or treatments that you request or your physician recommends are also your responsibility. If you do not have insurance, all fees are due at the time of service. *We accept Visa, Mastercard, Discover, CareCredit, Cash and Checks. Billing, Payments and Over Payments: If an overpayment is made by you, a refund will only be issued if there are no other outstanding debts on you or your family's account. Please inform us of changes in address, phone or employer. Returned Check Policy: You may be billed a $35 returned check fee or any fees that we incur as a result of your check being returned to our bank. Retail Goods Policy: Optical and low vision aid orders will not be placed without a deposit of half of the total. All orders should be picked up within 30 days. If orders are not picked up within a timely manner, products will be returned or re-stocked and any / all deposits will be forfeited. Refraction: Medicare some plans do not cover this service. You will be responsible for a fee of $45 should this apply to you. Cancellation Policy: When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient. We require that you give our office 24 hours notice in the event that you need to reschedule your appointment. This allows other patients to be scheduled into that appointment time. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. A fee of $25 will be charged to you; this fee cannot be billed to insurance and will be your direct responsibility. Additionally, if a patient is more than 15 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $25 cancellation fee will be charged.