Welcome to our officeTitleLast nameFirst nameMIDate(Mr., Mrs., Ms., Miss, Dr.)E-MailName you wish to be calledHome AddressCityStateZipAgeBirthdateSSNReferred By(Please mark preferred)Employer/SchoolOccupationName of Parent, Legal Guardian or SpouseName of family members whom we have provided careInsurance CompanyID#Subscriber
Subscriber NameRelationship to patientRace (Optional):Ethnicity (Optional):Preferred Language:Medical History / Review of Systems:List any medications you are now taking (including eye drops, birth control pills, vitamins, or over the counter medications):Are you allergic to any medications?Please list:Primary Care Physician:Pediatrician:Preferred Pharmacy:Location:Phone:Do you have or have you ever had any of the following problems:Gastrointestinal Problems
(ulcer, abdominalpain, diarrhea)
Asthma/COPDDiabetesHeart ProblemsHigh Blood PressureMusculoskeletal ProblemsNeurologic
(numbness, weakness, headaches, prior stroke)
High CholesterolThyroid ProblemsPsychiatric Problems (depression, axiety)ArthritisRespiratory Problems
(shortness of breath, wheezing)
Chronic fever, unexpected weight loss/gain, fatigueSeasonal AllergiesEar/nose/throat (hearing loss, sinus)Skin Problems (rashes, excessive dryness, rosacea)Endocrine ProblemsUrinary Problems
(pain or discomfort, blood in urine)
List any previous major injuries/surgeries/hospitalizations:Eye History: Do you have or have you ever had any of the following problems:Family History(Mother, Father, Grandparents, Siblings)Marital Status:Do you drive?If yes, do you have visual difficulty when driving?If yes, please describe:Smoking HistoryDo you drink alcohol?Do you use illegal drugs?Have you ever been exposed to or infected with:If patient is 18 or under, please complete:Any prenatal, perinatal, or postnatal problems?Any developmental problems?Do you have any concerns with your child's school performance?Last eye care provider:Date of last eye examAre you currently having eye or vision problems?If yes, please explainDo you wear glasses?How old are they?Are they bifocals?Are they forHave you ever worn contact lenses?If yes, when were they prescribed?Do you wear contacts now?If not, why did you quit?Are you interested in wearing contact lenses?If yes, please read the following information regarding contact lenses.Wing Eyecare prescribes quality contact lenses to improve your vision and your lifestyle. Contact lenses are FDA regulated medical devices that can cause discomfort, infections, and even permanent vision loss if not cared for properly. New and existing contact lens wearers require additional time and testing during an eye examination to minimize the risk of serious eye problems. This additional testing is only done for contact lens wearers, not for patients who do not wear contact lenses. For this reason, there are additional contact lens evaluation and service fees for new and existing contact lens wearers. Your contact lens evaluation and services fee includes:1. Specific curvature measurements of the corneas.
2. Evaluation of the current and new lenses to ensure optimal fit, vision and comfort.
3. Medical assessment of the cornea, tear film and conjuctiva as they relate to the contact lens wear.
4. Insructions regarding safe contact lens wear, care and proper cleaning and solutions.
5. Contact lens follow up care for 1 year.
If you have any questions, please do not hesitate to speak with your doctor.Payment for all services and products is the responsibility of the patient.
I agree to pay all copays, deductibles, co-insurances and non-covered services as determined by my insurance company.
I understand there is a returned check fee applied to every returned check.
I agree to pay an additional collection fee for all accounts not paid in the time stated on the final monthly statement.
I authorize the release of medical information concerning my illness and treatment by Wing Eyecare to my insurance company.
I also authorize the release of my personal medical information to any doctor to whom I may be referred.
I understand verification of eligibility is not a guarantee of payment as stated by my insurance company.
I authorize payment of my insurance benefits to Wing Eyecare.
We will file all insurance forms if Wing Eyecare is a participating provider for your plan.
We will supply you with an itemized statement which you may submit to your insurance carrier.
Signature of patient or legal guardianToday's Date