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Chart #:

Today's Date*

Name*

First Last

Phone*

Email Address*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

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:

Please list your employer:

Please list your occupation:

MEDICAL HISTORY

Name of Family Physician:

Date of Last Physical Exam:

Any NEW allergies to your medication list?

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.

EYE HEALTH HISTORY

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

Do you have a backup pair of glasses?

Yes
No

Have you ever been diagnosed or treated for the following in the past year(s) since your last visit with us?

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

If there are no changes to your medical history, please check below.

No changes

Is the patient also the insurance policyholder?

Yes
No

Primary policy holder name*

Primary policy holder DOB*

Policy holder last 4 SSN*

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

Name

First Last

Number

Test 1: Optomap Retinal Screener

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

As a previous patient, we did this same test last year. This allows our doctors to view the inside of your eye without the use of dilation drops unless dilation is necessary. Doing it every year allows for us to monitor any changes that may otherwise not be documented or noticed, which is why it is Premier Eye Centers standard of care and will be done today.

Tests 1: The $49 copay is part of today's copays(standard care)

Test 2: Glaucoma and Visual Field Testing(optional)

As in test 1 we utilize the newest technology for health screening. The Humphrey FDT Matrix will allow the detection of any changes related to glaucoma or pathology existing behind the eye. This also helps in the management of headaches and/or migraines, and rules out tumors.

Test 2 only: Glaucoma Screening Testing(optional)

I accept Test 2 $39.00
I decline Test 2 and no additional fee

Patient Signature*

By signing I acknowledge any fee's associated to my examination. I (patient or guardian) consent that all information I have submitted is accurate.

Date

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Necessary Information Data

MEDICAL HISTORY

EYE HEALTH HISTORY

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Premier Eye Center of Boca Raton

Premier Eye Center of West Palm Beach