Select Office*

Name*

First Last

Phone*

Email Address*

Address*

Street Address City

Patient's Date of Birth*

Primary Medical Insurance*

Vision Insurance*

Last 4 SSN*

If the policyholder is also the patient, click here

Yes
No

Primary policy holder name

Primary policy holder DOB

last 4 digits of your SSN

Member ID*

Today's Date

Please present BOTH Medical and Vision information NOW in order to insure that all benefits are applied appropriately to the fees today.

Necessary Information Data

Please check all that apply

Marital Status:

Single
Married
Divorced
Widowed

Employment Status:

Ethnicity:

(Required by the State of Florida)

Please list your employer:

Please list your occupation:

VERY IMPORTANT! NEW PATIENTS ONLY

Who may we thank for referring you to our office?

If not referred, how did you choose our office for your needs?

Another Doctor

Signage/Location

Insurance List

Newspaper

Flyer

Yellow pages

Web pages

(search engine)

I have reviewed and understand that the Premier Eye Center Privacy and patient Consent Policy is displayed in office, on our website, and I can ask for a copy (printing/electronic) of it at any time. I (patient or guardian) consent that all information I have submitted is accurate.

Signature

(Patient or Guardian)

Date

To have your chart accessible to someone else on your behalf for medical, financial concerns, please put name(s) below:

Name

First Last

Number:

If no name is entered and the patient is over 18 years old despite insurance coverage we will need written consent by the patient.

MEDICAL HISTORY

Name of Family Physician:

Date of Last Physical Exam:

Do you have any allergies to medications?

Yes
No

If yes, please explain:

List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):

Height:

feet inches

Weight:

lbs.

Are you currently pregnant or nursing?

Yes
No

Do you use tobacco products?

Yes
No

If yes:

Type Amount How long

Do you drink alcohol?

Yes
No

If yes:

Type Amount How long

Do you use recreational drugs?

Yes
No

If yes:

Type Amount How long

List major injuries, surgeries, and/or hospitalizations you have had

Do you currently, or have you ever had any problems in the following areas?

Constitutional

Fever, weight loss/gain

Yes
No

Integumentary (skin)

Yes
No

Neurological

Headaches/Migraines

Yes
No

Stroke / Seizures

Yes
No

Endocrine

Thyroid/Other/Glands

Yes
No

Ear, Nose, Mouth, Throat

Allergies/Sinus

Yes
No

Chronic Cough

Yes
No

Dry Throat/Mouth

Yes
No

Respiratory

Asthma

Yes
No

Chronic Bronchitis/Emphysema

Yes
No

Vascular/Cardiovascular

Diabetes

Yes
No

Heart Pain

Yes
No

High Blood pressure

Yes
No

Vascular Disease

Yes
No

Gastrointestinal

Crohnʼs Disease

Yes
No

Acid reflux/IBS

Yes
No

Genitourinary

Genitals/Kidney/Bladder

Yes
No

Bones/Joints/Muscles

Rheumatoid Arthritis

Yes
No

Muscle pain / Joint pain

Yes
No

Lymphatic/Hematologic

Anemia / Bleeding Problems

Yes
No

Allergic/Immunologic

Yes
No

Psychiatric

Yes
No

EYE HEALTH HISTORY

The information in this confidential case history form is critical to the evaluation of your vision and health.

Date of last eye exam:

By Whom:

Do you wear glasses?

Yes
No

Have you ever tried contact lenses?

Yes
No

Do you currently wear contact lenses?

Yes
No

What kind?

Solution used?

If you wear contact lenses, are you satisfied with the vision and comfort?

Yes
No

Do you have a backup pair of glasses?

Yes
No

Have you ever been diagnosed or treated for the following?

Do you experience or have you ever experienced:

MEDICAL CONCERN:

VISION CONCERN:

Blurry vision
Double vision
Night driving
Halos

Is there anything specific that you want to address today?

Such as:

Lasik
Contact Lenses
Blue light lens technology
Sports goggles
Transitions
UV protection
Other

If other, please specify:

FAMILY HISTORY

Blindness

Yes
No

Relationship

Cataracts

Yes
No

Relationship

Corneal Problems

Yes
No

Relationship

Crossed eyes/Lazy eyes

Yes
No

Relationship

Glaucoma

Yes
No

Relationship

Macular Degeneration

Yes
No

Relationship

Retinal Detachment

Yes
No

Relationship

Arthritis

Yes
No

Relationship

Cancer

Yes
No

Relationship

Diabetes

Yes
No

Relationship

Heart Disease

Yes
No

Relationship

High Blood Pressure

Yes
No

Relationship

Kidney Disease

Yes
No

Relationship

Lupus

Yes
No

Relationship

Thyroid Disease

Yes
No

Relationship

If you answered YES to any of the above or have a Condition not listed, please explain & list medications:

Is the the patient the insurance policyholder?

Yes
No

Primary policy holder name*

First Last

Primary policy holder DOB*

Policy holder last 4 SSN*

Test 1: Optomap Retinal Screener

We at Premier Eye Center perform a state-of-the-art digital scanning technology as part of yout annual medical eye exam.

This allow our doctors to view the inside of your eye without the use of dilation drops, unless dilation is necessary. The OPTOMAP allows the doctor to evaluate your retina for problems such as diabetes, high blood pressure, retinal rips, tumors, bleeding, and several other medical eye conditions. The doctor is also better able to evaluate and monitor any changes by comparing the images from year to year.

This scanning system is safe for both kids, adults and during pregnancy.

Test 1: The $49 copay is incorporated into today's copays (standard care).

It is strongly recommended that ALL patients have a thorough examination of their retina every year. Without the Optomap or a dilated examination, serious eye conditions can be missed. Dilation may still be required.

Test 2: Glaucoma and Visual Field Testing(optional)

We utilize the newest technology for glaucoma screeing the Humphrey FDT Matrix. This will detect any changes related to glaucoma or pathology existing behind the eye. The technology also give information regarding the visual pathway from the brain to the eyes. This helps in the management of headaches and/or migraines, and rules out potential consequences such as tumors or brain masses. If treatment is necessary, our doctors are able to treat and manage eyes disease-related to abnormal visual fields.

I elect to have the FDT Matrix screener Original Price ~~$100.00~~ Now $39.00
I decline addintional FDT Matrix screening

Signature

By signing I acknowledge any fee’s associated to my examination

Date

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