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Patient Information
* REQUIRED
Patient Name:*
Social Security:*
Home Phone:*
Work Phone:
Address:*
City:*
State:*
Zip:*
Date Of Birth:*
/ /
ex:01/02/1965		 Sex:*
Male Female
Marital Status:*
Married Single Widowed Divorced
Additional Patient Information
Alternate Phone:
Cell Phone:
Pager:
Fax:
Email:
 
Emergency Contact
Name:*
Phone:*
Insurance Information*
Primary Insurance:
ID:
Insurance Address:
Date Of Birth:
/ /
ex:01/02/1965
Zip:
State:
Self Pay
Policy Holder General Information
Policy Holder Name:
Policy Holder Social Security:
Policy Holder Phone:
Policy Holder Work Phone:
Policy Holder Address:
Policy Holder Employer:
Policy Holder Relation To Patient:
 Policy Holder Date Of Birth:
- -
ex:01/02/1965
Second Insurance Information
Insurance:
ID:
Name Of Policy Holder:
Policy Holder Date Of Birth:
- -
ex:01/02/1965
Policy Holder Social Security:
Policy Holder Phone:
Medical Information
Pharmacy Number:
Primary Doctor:
Doctor Phone:
 
Nature Of Complaint:
Accident Related:?
yes no		 Work Related:?
yes no
Explain How Injury Occured:
History Record
Please answer the following questions about your medical health.

Have you been treated for any medical conditions such as Diabetes, High Blood Pressure or Arthritis?
Have you been hospitalized or had surgery?
Do you have any allergies to drugs or food?
Do you take any medications including eye drops?
Do you take any medical or eye conditions run in your family? (High blood pressure, diabetes, cataracts, or glaucoma)
Do you smoke?
Do you drink?


If any of the following eye condition apply to you please check the boxes below with a brief explanation.

WEARS GLASSES/CONTACTS
DECREASED VISION
BLIND SPOT (S) IN VISION
POOR SIDE/NIGHT/COLOR VISION
ABNORMAL LIGHT SENSITIVITY
HALOS AROUND LIGHT
RED/PUFFY EYES
DRY/ITCHY EYES
PRESSURE BEHIND EYES
ABNORMAL TEARING
DISCHARGE/CRUSTY EYES
FLUCTUATING/DOUBLE VISION
FLOATERS/JAGGED LINES IN VISION
FLASHING LIGHTS IN VISION
PAST EYE INJURY (SURGERY/LASER)
LAZY EYE
ABNORMAL PUPIL
CORNEAL DISEASE/CONDITON
GLAUCOMA
RETINAL DISORDER/CONDITON
CROSSED EYES AS A CHILD


Do you currently have any of the following problems? If 'Yes', please explain:

ENDOCRINE PROBLEMS (DIABETES, THYROID, GLANDULAR)
CRONIC FEVER, UNEXPECTED WEIGHT LOSS/GAIN, FATIGUE
EAR/NOSE/THROAT PROBLEMS (SINUSITIS, HEARING LOSS)
HEART PROBLEMS (CHEST PAIN, IRREGULAR HEART BEAT)
RESPIRATORY (SHORTNESS OF BREATH, WHEEZING)
GASTROINTESTINAL PROBLEMS (HEARTBURN, VOMITING)
URINARY PROBLEMS (PAIN/DISCOMFORT, BLOOD IN URINE)
SKIN PROBLEMS (RASHES, EXCESSIVE DRYNESS)
MUSCULOSKELETAL PROBLEMS (JOINT PAIN, MUSCLE ACHES)
PSYCHIATRIC PROBLEMS (DEPRESSION, ANXIETY)
Appointment Request
1st Requested Date:
/ /
ex:01/02/1965 		2nd Requested Date:
/ /
ex:01/02/1965
Reason For Requesting Appointment:
PATIENT IS RESPONSIBLE FOR OBTAINING ALL REFERRALS*
I HEREBY AUTHORIZE ASSIGNMENT OF BENEFITS TO BE PAID DIRECTLY TO DOCTORS; NATTIS, NUDELMAN, MARCUS, HSU, LAMONICA, GROSS, SALZNAS. THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTILL REVOKED BY ME IN WRITING. A PHOTOCOPY OF THIS AGREEMENT IS TO BE CONSIDERED VALID AS AN ORIGINAL. THE PATIENT IS RESPONSIBLE FOR ALL FEES REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICE WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE. I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT IN FULL FOR ALL COINSURANCE AND DEDUCTIBLE COSTS, AS WELL AS ANY DOCTOR’S SERVICES WHICH ARE DETERMINED TO BE NON-COVERED OR DENIED. I AUTHORIZE MY PHYSICIAN TO RELEASE ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY BILL.

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