Welcome Sheet

Welcome to Grand Ridge Eye Clinic

Please complete this form and return it to the front desk with your insurance cards and photo ID. Thank you!

Reason for visit:

Date:

Gender:

Name:

Date of Birth:

Social Security Number

Address:

City/State/Zip:

Home #

Cell#

Email

How do you prefer to be notified?

Phone Call

Email

Are you the Billpayer?

Bill Payer’s date of birth

Employer

Occupation

Primary Care Physician

Date of last eye exam

Who may we thank for referring you, how did you hear about us?

Allergies (medications/environmental)

Medications (Including over-the-counter, drops, etc.)

Custom Lens Questionnaire

Hobbies

How many hours per day do you spend using electronics? (computer/phone/TV, etc.)

How many hours per day do you drive?

Daytime

Night time

List any complaints you have in your current glasses?

What do you like most about your current glasses?

Rank these in importance

1. Most important 2. Somewhat important 3. Least important

Fit of frames

Fashion

Function of glasses

How do you use your glasses? (check all that apply)

Patient Ocular History (check all that apply)

Family Medical History (check/circle all that apply)

Cancer:

Hypertension:

Diabetes:

Thyroid:

Other:

Family Ocular History (check/circle all that apply)

Amblyopia(lazy eye):

Macular Degeneration:

Strabismus:

Dry Eyes:

Cataract:

Severe Myopia:

Nystagmus:

Other:

Patient Review Of Conditions (Check All That Apply & Fill In Not Listed. Leave Blank If No Condition Exists)

Constitution

Cardiovascular

Gastrointestinal

Integumentary

Immunological

Psychiatric

Endocrine

Ear/Nose/Throat

Neurological

Musculoskeletal

Genitourinary

Blood/Lymphatic

Respiratory

Other Symptoms:

Patient Social History (check all that apply)

Do you drink alcohol?

Do you use tobacco?

Smoking Status:

Release of Information

I authorize the release of my information to the following (contact front desk to add a secondary person):

Name of authorized person:

Date of Birth

Relation

Receipt of Notice of Privacy Policy/Late Arrival/No-Show Policies

I, the patient, have read a copy of this office's Notice of Privacy Practices and have been informed of the late arrival and no show fee policies as well.

Print Patient Name

Date

Financial Responsibility

We will be happy to file your insurance claims for you and will do all we can to help you receive the maximum benefits. However, in the event that your insurance determines that you are not eligible for coverage at the time of service, or makes a determination that you are eligible for a reduced level of coverage, by signing this statement you hereby agree to be financially responsible for any and all charges incurred by you and not paid by the insurance.

Print Name

Signature

Date

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