BRIDGEPORT EYE CENTER

Mr. Mrs. Ms. Dr. Miss
(please check one)

Name:___________________________________________Nickname:_________________
            Last Name                               First Name                          MI           Suffix

Address: _____________________________ City:_________________ State:_____ Zip:______

Phone:(____) ____-______ Alt. Phone:(____) ____-______ Alt. Phone: (____) ____-______

SS#: _____-____-______ Email:_____________________________ Date of Birth:___/___/____
           (required for insurance)
Work in the home Student Retired Employed- Occupation: ____________________
                                                     (please check one)
Sex: M F      Single ___ Married ___ Divorced ___ Widowed___
  (please check one)                                           (please check one)

Employer: ______________________________________ Phone: (____) ____-____
                         name

Emergency Contact ________________Phone (____) ____-_____Alt. Phone (____) ____-_____

Insurance Information

Our office files some types of insurance. If you will be attempting to use insurance for your visit today you must present your insurance card to the receptionist PRIOR to being seen by the doctor. Some types of insurance we do not file directly but we will help you to file so that you may be reimbursed by your carrier for expenses in our office.

It is the responsibility of the patient to be certain that you are covered for services and that you inform the staff of you benefits when completing this form. The staff will verify your benefits with your carrier. If your appointment is delayed due to benefit verification, the appointment may be rescheduled. All co-pays are due on the date of service. No minor may be examined without a parent in the room.

We do not verify benefits after an appointment has been completed. No exceptions. In other words, if you do not have proof of coverage and benefits verified you may NOT present this information at a later date and have a claim filed on your behalf. It is the patient’s responsibility to know who their insurance carrier is.

Insured’s Name:________________________________________________
                                    Last Name                               First Name                         MI                 Suffix

Relationship: Self Spouse Child Other   Sex: Male Female
                                                    (please check one)                                     (please check one)

Address: _____________________________ City:_________________ State:_____ Zip:______

Phone (____) ____-_____ DOB:___/___/_____ SSN: ____-___-____

 

Chief Complaint

Why are you here today? _________________________________________________________

Did a doctor refer you? Yes ____ No ____ Name ____________________________________
                                             (please check one)

Do you wear glasses? Yes No
                                  (please check one)
Type of glasses? Single vision/reading Bifocal Trifocal Progressive
                                                    (please check one)
Do you wear contact lenses? Yes No
                                             (please check one)
Type of contact lenses: Rigid Soft Yearly Disposable Other ________________

Eyes: (please check all that apply)
Blurred Vision Stinging/Burning Excess watering/tearing
Flashes/Floaters Red/Itchy Other, ______________________
                                 (please explain)

Medications (including any eye drops and over the counter medications)
Medication Dose Reason for Medication Side Effects

Previous Eye Dr. ___________________________ Phone(___) ____-_____ Last exam: _____
                                   Name                                     City/State

Primary Care Physician: _______________________ Phone(___) ____-_____Last exam: ____
                                        Name                                  City/State

Review of Symptoms:
Are you currently having or have you had any problems with your

Circle One Describe all Yes responses
Skin Yes  No __________________________________
Headaches, Migraines, Seizures Yes  No __________________________________
Thyroid Yes  No __________________________________
Ears, nose, throat, mouth Yes  No __________________________________
Respiratory Yes  No __________________________________
Diabetes Yes  No __________________________________
High Blood Pressure Yes  No __________________________________
Heart Pain Yes  No __________________________________
Gastrointestinal Yes  No __________________________________
Genito-Urinary Yes  No __________________________________
Rheumatoid Arthritis/Joint Pain Yes  No __________________________________
Bleeding Problems/Anemia Yes  No __________________________________
Allergic/ Immunologic Yes  No __________________________________
Psychological problems Yes  No __________________________________
Are you pregnant or nursing? Yes  No __________________________________

Past Medical History
Surgeries/Hospitalizations Year Complications

Family History
Member Any chronic illness or eye diseases? Ex. Hypertension, Diabetes, Cataracts, Glaucoma
Grandmother (mom’s)
Grandfather (mom’s)
Grandmother (dad’s)
Grandfather (dad’s)
Father
Mom
Sister/Brother
Sister/Brother
Sister/Brother

Are you allergic to any Medications? Yes No (please check one)

If yes, please list: _________________________________________________________

Social History
History of substance abuse? No Yes What?_____________________________________

Smoke currently? No Yes _____ Packs per day for _________ years

Drink alcohol? Daily 1-2 times a week 1-2 times a month 1-2 times a year Never

Have you been infected or exposed to any of the following: HIV/AIDS Hepatitis

 

HIPPA COMPLIANCY FORM

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I have reviewed the Bridgeport Eye Center’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed.
If you are not familiar with the Privacy Practices, a viewable copy is available at the front desk.

 

_____________________________________    ______________________________
Patients Printed Name                                             Date of Birth

 

_____________________________________   ______________________________
Signature of Patient or Legal Representative           Date

 

_____________________________________

If Legal Representative, Relationship