Patient Name

First Last

Birthdate

Last Eye Doctor

Reason for Last Visit

Date of last eye exam

Primary Care Physician

Date of last visit

Contact Lens History

Brand of current contact lenses?

How often do you replace your contacts?

Normal wearing hours?

Overnight?

Yes
No

Everyday Wear?

Yes
No

Occasional?

Yes
No

Current Glasses Information

Age of current glasses?

1 yr
2 yr+

Age of sunglasses?

1 yr
2 yr+

Do you use glasses for

Computer
Sports/Fishing/Hunting
Reading
Near work/Hobbies

Medical Alerts

Please list all medical alerts
(i.e. epilepsy, DNR / DNI)

Do you have a medical history of any of these conditions

Diabetes

Yes
No

High Blood Pressure

Yes
No

Kidney Disease

Yes
No

Allergic / Immunologic

Yes
No

Heart Disease

Yes
No

High Cholesterol

Yes
No

Endocrine/Hormonal

Yes
No

Lupus/Rheumatoid Arthritis

Yes
No

Glaucoma

Yes
No

Retinal Disease

Yes
No

Macular Degeneration

Yes
No

Thyroid

Yes
No

Dry Eye

Yes
No

Eye Injury

Yes
No

Amblyopia

Yes
No

Cataracts

Yes
No

Cancer

Yes
No

Strabismus

Yes
No

Blindness

Yes
No

Medications

Please list all prescriptions, over the counter and herbal medications

Medication Name	Strength	Directions

Drug Allergies

Allergy	Onset Date	Reaction	Severity

Does anyone in your family have any medical history of

Social History

What type of recreational drugs do you use?

What type of alcohol do you drink, how much and how often?

Are you a smoker, former smoker or never smoked? Do you smoke everyday or some days?

What type of tobacco do you use, how much, how often and for how long?

Occupation

Work status / duties

Hobbies

Eye Surgical Information

Date	Eye	Procedure	Surgeon	Complications

Southern Eye Care Financial Policy

We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies.

1. Professional fees are due when services are rendered. A deposit of 50% is required towards the total cost of glasses or contacts before an order can be placed. The balance is due in full at the time of dispensing. We accept personal checks, cash, Discover, Visa MasterCard and CareCredit.

2. When glasses or contacts are purchased through VSP or any other insurance, the balance is due in full when the order is placed.

3. Keep in mind that your insurance policy is basically a contract between you and your insurance company. As a service to you, we will file your insurance claim if you assign the benefits to the doctor.

4. If your insurance company does not pay the practice within 45 days, you are responsible for all fees due.

5. If you are insured by a plan that we do not accept, we will prepare and send the claim for you on an unassigned basis. Therefore, our charges for your care are due at the time of service.

6. Not all-insurance plans cover all services. In the event your insurance plan determines a service to be “not covered,” you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.

I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.

Signature of patient

(or responsible party, if minor)

Date

Payments can be made through CareCredit at no interest for 6 months.
www.carecredit.com or call 1-800-365-8295 to apply.