New Patient Form - Stonebridge Eye Care

Patient Paperwork

Name*
First Middle Last
Preferred Name*
Gender*
Marital Status*
Spouses Name (if applicable)
Parent’s or Guardian’s Names (if minor)
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Month
Day
Year
Age*
Last 4 of S.S.N.*
Height*
Weight*
Eye Color*
Home Phone*
Cell Phone*
Work Phone*
Email*
Preferred Language*
- English
- Spanish
Employer*
Position*
For Students - School/Univ or Grade
Race*
- American Indian
- Asian
- African American
- Latino-Hispanic
- Hawaiian-Pacific Islander
- Arabic
- Caucasian
Ethinicity*
- Latino-Hispanic
- African American
- White
- Arabic
Preferred Communication From Our Office*
- Text Message
- Email
- Cell Phone
- Home Phone
- US Mail
Check all that apply
- I WOULD LIKE TO RECEIVE APPOINTMENT REMINDERS BY TEXT MESSAGE OR EMAILS. I UNDERSTAND THAT THERE MAY BE CHARGES TO MY PHONE BILL DEPENDING ON MY PHONE MESSAGING PLAN. PLEASE CHECK BOX INDICATING THIS IS APPROVED
Emergency Contact*
Phone Number*
Relationship*
Primary Care Provider and Phone Number*
Last Physical Exam*
Month
Day
Year
Preferred Pharmacy*
Pharmacy Phone Number*
How did you learn about our office?*
Name of Person Who Referred You Here.*
List family members who are patients here
Eye Examination History
Date of Last Eye Exam*
MM slash DD slash YYYY
Name of Last Eye Doctor*
Would you like help in selecting new eyewear today?*
- Yes
- Not Today
Do You Wear Eyeglasses?*
- Yes
- No
- Part-time
Type of Glasses*
- Reading
- Driving
- Computer
- Hobby
- Sports
- Sunglasses
Are You Interested In Lasik?*
- Yes
- No
- Not Sure
Do You Wear Contact Lenses?*
- Yes
- No
- Part-Time
What Type of Contact Lenses*
- Soft
- Rigid
- 1 Day Disposable
- 2 Week
- 1 Month
- 3 Month
Brand Name of Contact Lenses*
What Contact Lens Solution Do You Use?*
Eye Health History
Please Check All That Apply*
- Crossed Eyes
- Lazy Eye
- Droopy eyelids
- Glaucoma
- Macular Degeneration
- Cataracts
- Retinal Detachment
- Dry Eye
- Eye Infections
- Herpes of the Eye
- Fuch's Dystrophy
- Keratoconus
- Light Sensitivity
- Watery Eyes
- Floaters
- Eye Allergies
- Cataract Surgery
- Lid Surgery
- Retina Surgery
- Eye Muscle Surgery
- Lasik
- PRK
- RK
- Glaucoma Surgery
- Eye Injury
- None
General Health History
List All Current Medications Being Used
List Eye Drops Currently Being Used
List Allergies to Medications
Are You Pregnant?*
- Yes
- No
Are You Nursing*
- Yes
- No
Please Check All That Apply*
- Diabetes Type 1
- Diabetes Type 2 Hypoglycemia
- Crohn’s Disease
- Kidney Disease
- Prostate Cancer
- Ulcerative Colitis
- IBS
- Prostate Enlargement
- None
Please Check All That Apply*
- High Blood Pressure
- Carotid Artery Disease
- Stroke History
- Heart Disease
- Dermatomyositis
- None
Please Check All That Apply*
- Anemia
- Leukemia
- Osteoarthritis
- Osteoporosis
- Rheumatoid Arthritis
- Fibromyalgia
- Myeloid Disease
- Lymphoma
- Sickle Cell
- Lupus
- Hepatitis
- Sarcoidosis
- Osteogenesis Imperfecta
- Sjogren’s Syndrome
- Raynaud’s Disease
- Thyroid Disease
- HIV +
- None
Please Check All That Apply*
- Anxiety
- Depression
- Bi-Polar Disorder
- Seizures
- Concussions
- Headaches
- Ocular Migraine
- Multiple Sclerosis
- Vertigo
- None
Please Check All That Apply*
- Seasonal Allergies
- Sleep Apnea
- Asthma
- Bronchitis
- COPD
- Tinnitus (Ringing)
- Emphysema
- Hearing Loss
- None
Please Check All That Apply*
- Hearing Loss
- Hives/Rashes
- Fever Blisters
- Skin Cancer Cancer
- None
Please Check All That Apply*
- Pacemaker
- Requiring a wheelchair
- None
Hepatitus Type*
Skin Cancer Type*
Family Medical History
Check all that apply and list family member.
- High Blood Pressure
List Relation*
- Diabetes
List Relation*
- Cancer
List Relation and Type of Cancer*
- Heart Disease
List Relation*
- Arthritis
List Relation*
- Macular Degeneration
List Relation*
- Lazy Eye
List Relation*
- Retinal Detachment
List Relation*
- Glaucoma
List Relation*
- Blindness
List Relation*
Social History
Do you smoke?*
- Yes
- No
Do you use smokeless tobacco products?*
- Yes
- No
Have you tried a tobacco use cessation program*
- Yes
- No
Do you drink alcohol?*
- Yes
- No
Do you use illegal drugs*
- Yes
- No
Do you drive a motor vehicle?*
- Yes
- No
Major Medical and Vision Insurance Information
Name*
Date*
MM slash DD slash YYYY
Major Medical Insurance Information

This information is required to complete any insurance claims on the patient’s behalf. Information submitted here must be current, accurate, complete and legible in order for the appropriate claim to be submitted. If you have any questions about completing this section, please ask the front desk staff member for assistance.

This information is required and must be correct in order for our office to file your claim.
Major Medical Insurance*
Insured ID*
Group #*
Member's Full Name*
Member's Birthdate*
Month
Day
Year
Relationsip to Insured*
Member's Address*
Street Address Address Line 2 City State ZIP Code
Member's Phone*
Member's Employer*
Vision Insurance Information
Vision Insurance Name*
Insured ID*
Group #*
Member's Full Name*
Member's Birthdate*
Month
Day
Year
Relationship to Insured*
Member's Address
Street Address Address Line 2 City State ZIP Code
Member's Phone*
Member's Employer*
I HAVE COMPLETED THIS INFORMATION PACKET AND UNDERSTAND THAT INCORRECT OR FALSE INFORMATION MAY RESULT IN UNPAID CLAIMS. I UNDERSTAND THAT I AM RESPONSIBLE FOR UNPAID CLAIMS. I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT AT THE TIME SERVICES ARE RENDERED AS WELL AS APPLICABLE COPAYMENTS AND FEES APPLIED TO DEDUCTIBLES. I AGREE TO PAY FOR ALL BILLED SERVICES AND MATERIALS TODAY. I UNDERSTAND THAT I AM RESPONSIBLE FOR SERVICE AND MATERIAL FEES IF DR. WRIGHT IS NOT A PROVIDER FOR MY INSURANCE. I UNDERSTAND THAT IF I AM THE RESPONSIBLE PARTY FOR A MINOR PATIENT THAT ALL OF THE ABOVE SAID STATEMENTS ARE MY RESPONSIBILITY. MY SIGNATURE BELOW INDICATES I HAVE READ AND AGREE TO THESE STATEMENTS REGARDING THE BILLING AND PAYMENT FOR MY CARE AND SERVICES PROVIDED AT THIS OFFICE.
Date*
MM slash DD slash YYYY
Signature*
Acknowledgement of Receipt of Privacy Policy
Name*
Date*
MM slash DD slash YYYY
Signature*
Permission to Leave Telephone Messages
- Please check this circle to give us permission to leave phone messages regarding your appointment times, requests for return calls or the status of orders pertaining to this office.
Initials*
Permission to Share Personal Health Information
Listed below are the names and phone numbers of individuals for whom I am giving permission to access information or materials from this office which pertain to me, my health status, my personal health record and all other information contained within this office or its electronic data base.

(Our office is required to offer this option and to abide by your wishes.)
List
Name Phone Number Date Permitted Date Removed

Name	Phone Number	Date Permitted	Date Removed

Patient Paperwork

Eye Examination History

Eye Health History

General Health History

Family Medical History

Social History

Major Medical and Vision Insurance Information

Major Medical Insurance Information

Vision Insurance Information

Acknowledgement of Receipt of Privacy Policy

Permission to Leave Telephone Messages

Permission to Share Personal Health Information