New Patient Form | Information Form for New Eyecare Patients

Thank you for choosing our practice for your eye care needs. Please complete the following. If you have any questions or concerns, please do not hesitate to ask for assistance. To prevent any misunderstandings, we have a stated payment policy. Payment in full is expected at the time services are provided. Payment may be made with cash, check, Mastercard, Visa, Discover, or an insurance program for which we accept assignment. If eyeglasses or contact lenses are to be ordered we require payment in full. Any balance owed must be paid in full when materials are dispensed.

Patient Information

Name*

Prefix First Middle Last

Nickname

Sex*

Male
Female

Home Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Secondary Phone

Email*

What is your contact preference?

Phone
Email
Text

DOB*

Occupation*

Employer*

Spouse/Parent's Name (if minor)

Spouse/Parent's Employer (if minor)

I authorize Perimeter West Eye Care to release my medical and/or billing information to the following individuals:

Name

Relationship

Name

Relationship

Name

Relationship

Signature - Information*

Insurance Information

A copy of your card will be required.

Vision Discount Plan

As of 11/01/2017 EyeMed changed their policies and no longer allows us to utilize routine vision benefits when billing medically (coordinate benefits). Additionally, in a few cases, it may also affect your contact lens service fees. Please contact our office, 614-789-5559, if you have any questions prior to your appointment.

Medical Insurance

Name of Primary Insured*

Date of Birth of Primary Insured*

Primary Insured's Last Four Digits of SSN*

Relationship to Patient*

Authorization

Must be signed for insurance purposes.

I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.

Signature - Authorization*

Privacy Notice

I acknowledge I have received a copy of Perimeter West Eye Care's Financial Policy and Privacy Policy.

Signature - Privacy and Financial Policy*

Date*

Whom may we thank for referring you to our office?

What brings you in today? (Please check all that apply)

Glasses
Contact Lenses
Dr. Requested Follow-Up
Eye Allergies
Eye Irritation
Eye Infection
Headaches
Flashes/Floaters
Lasik Consultation

Ocular Symptoms (Please check all that apply)

Patient's Medical Health History

Patient's Ocular Health History (Please check all that apply)

Eye Injuries/Surgeries

Eye Medications/Drops

Full Name of Your Primary Care Physician

Family's Medical Health History

Has anyone in your immediate family suffered from:

Dry Eyes

Yes
No

Relationship to patient

Eye Injuries

Yes
No

Relationship to patient

Strabismus (Eye Turns)

Yes
No

Relationship to patient

Blindness

Yes
No

Relationship to patient

Cataracts

Yes
No

Relationship to patient

Glaucoma

Yes
No

Relationship to patient

Retinal Detachment

Yes
No

Relationship to patient

Keratoconus

Yes
No

Relationship to patient

Color Vision Problems

Yes
No

Relationship to patient

Amblyopia (Lazy Eye)

Yes
No

Relationship to patient

Macular Degeneration

Yes
No

Relationship to patient

Has anyone in your immediate family been diagnosed with Cancer?

Yes
No

Type? Relationship to patient

Has anyone in your immediate family been diagnosed with Diabetes?

Yes
No

Type 1 or Type 2? Relationship to patient

Has anyone in your immediate family been diagnosed with Hypertension?

Yes
No

Relationship to patient

Has anyone in your immediate family been diagnosed with Thyroid Disorder?

Yes
No

Relationship to patient

Other relevant medical history in your immediate family?

Yes
No

Explanation of Problem

Review of Systems

Constitutional (changes in weight, sleep)

Yes
No

Explanation of Problems

Ear, Nose, Throat

Yes
No

Explanation of Problems

Neurology (headaches, MS, tumors)

Yes
No

Explanation of Problems

Psychiatric (depression, anxiety, ADD, autism)

Yes
No

Explanation of Problems

Cardiovascular (heart disease, high blood pressure)

Yes
No

Explanation of Problems

Respiratory (asthma, emphysema)

Yes
No

Explanation of Problems

Gastrointestinal (ulcers, reflux, IBS)

Yes
No

Explanation of Problems

Genitourinary (genitals, kidneys, bladder)

Yes
No

Explanation of Problems

Bones/Joints/Muscles (arthritis, MD)

Yes
No

Explanation of Problems

Skin Disorders (rosacea, lupus)

Yes
No

Explanation of Problems

Blood/Lymph

Yes
No

Explanation of Problems

Allergy (seasonal, foods, medications)

Yes
No

Explanation of Problems

Cancer

Yes
No

Explanation of Problems

Currently Pregnant

Yes
No

Explanation

Currently Nursing

Yes
No

Explanation

Endocrine (diabetes, thyroid)

Yes
No

Last Hemoglobin A1C?

How frequently do you see your endocrinologist?

Full name of endocrinologist?

List all medications, supplements, and over the counter medicine you take on a routine basis.

Are you allergic to any medications?

Yes
No

List all medication allergies.

Social History

Do you use tobacco products?

Yes
No

Type/Amount/How Long?

Do you drink alcohol?

Yes
No

Type/Amount/How Long?

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