NEW PATIENT INFORMATION

*Please remember to arrive 15 minutes before your scheduled appointment. Please bring your insurance card(s) and photo ID to your appointment. Patients under age 18 MUST be accompanied by a parent or legal guardian.

*If you are feeling ill, running a fever, or having any serious respiratory symptoms, we kindly ask that you give us a call to reschedule your appointment.

Patient Name

First Name

Middle Initial

Last Name

Birth Date

Please list your height in Feet/Inches:

Weight:

Are you pregnant or nursing?

Yes No

Are you:

Right Handed Left Handed

Address

Street Address

Street 2 Address

City

State / Province

Postal / Zip Code

Phone Number

no dashes or spaces

If other preference, explain here:

Race/Ethnicity

Language Preference

Check the box that applies:

Single

Married

Widowed

Employed

Part-Time Student

Full-Time Student

Employer:

School Name:

EMERGENCY CONTACT INFORMATION

Emergency Contact:

First and Last Name

Relationship to patient

Home Phone

no dashes or spaces

Work Phone

INSURANCE (POLICY HOLDER'S INFORMATION)

Insurance Company Name

Policy/Member ID#

Policy Holder's Name

First and Last Name

Policy Holder's Birth Date

Policy Holder's Phone Number

no dashes or spaces

Policy Holder's Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

DOCUMENTS Please upload Front and Back of Insurance card(s)

Add file

Please upload a file

VISUAL AND MEDICAL HISTORY

Date of last eye exam

I don't know Date

Date

Please enter the name of who performed the last eye exam

I don't know Name

Name

Do you presently wear:

Eyeglasses Contacts Both Neither

How old are your glasses?

How old are your contacts?

Brand of contact lenses?

Are your contacts comfortable?

Yes No

Name of Medical doctor:

Phone Number

no dashes or spaces

List all of your current medications with dosage and usage or upload below (include oral contraceptives, aspirin, otc and or herbal meds.)

Medication List Upload photo of Med List

Add file

Please upload a file

Do you have allergies to any medications?

Yes No

If yes please list & specify reaction:

Do you have allergies to latex?

Yes No

List all surgeries and/or hospitalizations you have had:

FAMILY MEDICAL HISTORY

Please select relationship to any medical history or none for every option.

DISEASE/CONDITION

Blindness

Mother

Father

Sister

Brother

None

Unknown

Cataract

Mother

Father

Sister

Brother

None

Unknown

Glaucoma

Mother

Father

Sister

Brother

None

Unknown

Lazy Eye

Mother

Father

Sister

Brother

None

Unknown

Macular Degeneration

Mother

Father

Sister

Brother

None

Unknown

Retinal Detachment

Mother

Father

Sister

Brother

None

Unknown

Retinal Disease

Mother

Father

Sister

Brother

None

Unknown

Cancer

Mother

Father

Sister

Brother

None

Unknown

Arthritis

Mother

Father

Sister

Brother

None

Unknown

Diabetes Type 1

Mother

Father

Sister

Brother

None

Unknown

Diabetes Type 2

Mother

Father

Sister

Brother

None

Unknown

Heart Disease

Mother

Father

Sister

Brother

None

Unknown

High Blood Pressure

Mother

Father

Sister

Brother

None

Unknown

Kidney Disease

Mother

Father

Sister

Brother

None

Unknown

Lupus

Mother

Father

Sister

Brother

None

Unknown

Thyroid Disease- Hyper

Mother

Father

Sister

Brother

None

Unknown

Thyroid Disease- Hypo

Mother

Father

Sister

Brother

None

Unknown

REVIEW OF SYSTEMS

Do you currently, or have you ever had any issues in the following areas: (Check the box if your answer is yes )

Constitution

Developmental Disabilities

Cancer

Fatigue Syndrome

None

ENT

Hearing Loss

Sinusitis

Dry Mouth

Laryngitis

None

Neurological

Multiple Sclerosis

Epilepsy

Cerebral Palsy

Tumor

Stroke/CVA

Migraine

Autism Spectrum Disorder

None

Psychiatric

Depression

Attention Deficit

Anxiety Disorder

Bipolar Disorder

None

Cardiovascular

Hypertension

Heart Disease

Vascular Disease

Congestive Heart Failure

None

Respiratory

Cigarette Smoker

Asthma

Bronchitis

Emphysema

Chronic Obstruction

Sleep Apnea

None

Gastrointestinal

Crohn's

Colitis

Ulcer

Acid Reflux

Celiac Disease

None

Genitourinary

Kidney Disease

Prostate Disease/Cancer

STD/STI

Benign Prostate Hypertrophy

Pregnant

Past Pregnancy

*Not currently pregnant

none

Muscular/Skeletal

Arthritis

Osteoarthritis

Fibromyalgia

Muscular Distrophy

Ankylosing Spondylitis

Osteoporosis

Gout

None

Integumentary(Skin)

Eczema

Rosacea

Psoriasis

Cold Sores

Shingles

None

Endocrine

Type 2 Diabetes

Type 1 Diabetes

Thyroid Dysfunction

Hormonal Dysfunction

None

Hematologic/Lymphatic

Anemia

Large-Volume Blood Loss

Ulcer

Hypercholesteremia

None

Allergic/Immunologic

Drug Allergies

Environmental Allergies

Rheumatoid Arthritis

Lupus

Sjogren's Syndome

None

If you marked any of the above or have a condition not listed, please explain:

SOCIAL HISTORY

(This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.)

Do you drink alcohol ?

Yes No

If yes, type/amount/how long

Do you use other tobacco products?

Yes No

If yes, type/amount/how long

Do you vape?

Yes No

If yes, type/amount/how long

Do you use illegal drugs?

Yes No

If yes, type/amount/how long

Are you a smoker:

Yes No

I, the patient/guardian/responsible party, have accurately and truthfully completed the information listed on this form.

Patient/Guardian Signature

Type your full name for your digital signature

Date

Relationship to Patient

Patient Responsibility

Individual’s Financial Responsibility

I understand that I am financially responsible for my health/vision insurance deductible, coinsurance, or non-covered services.
Co-payments are due at the time of service.
If my plan requires a referral, I must obtain it prior to my visit.
In the event that my insurance plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of ALL services provided.
If I am uninsured, I agree to pay for the medical services rendered at the time of service.

Insurance Authorization for Assignment of Benefits

I hereby authorize and direct payment of my insurance benefits to Corridor Family Eyecare on my behalf for any services provided to me by the office.

Patient/Guardian Signature

Type your full name for your digital signature

Date

Relationship to Patient

HIPAA- ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

Link to HIPAA: https://corridorfamilyeyecare.com/wp-content/uploads/2018/08/HIPPA-Privacy-Form.pdf

I was given and have read Corridor Family Eyecare Notice of Privacy Practice and agree to continue my care with Corridor Family Eyecare under said terms.

Patient/Guardian Signature

Type your full name for your digital signature

Date

If you are signing as a personal representative of the patient, please indicate your relationship.

Relationship to Patient

I give permission to Corridor Family Eyecare to discuss my health care needs and release any product to, if I am unable to speak with them personally.

Name

First and Last

Relationship to Patient

Phone Number

Name

First and Last

Relationship to Patient

Phone Number

Vision vs. Medical Insurance

Most people have both vision and medical insurance. They are very different in the terms of the services they cover and it’s important to understand those differences. Vision coverage is mainly designed to determine a prescription for glasses, help pay for glasses or contacts, and to screen for medical conditions. It is not designed to be used for medical conditions, diagnostic or screening tests, or treatment plans. Some medical plans have a vision benefit.

When a medical diagnosis or condition is present (such as diabetes, high blood pressure, etc.) or an eye disease (such as infections, dry eye, allergies, cataracts, etc.) it is necessary to file the claim for your visit to your medical plan, and the co-pays, co-insurance, non-covered services, and deductibles apply. Vision insurance does not cover medical eye problems. Our office does not make the rules; they are defined by insurance carriers and we are required to follow them.

In most cases, it is difficult to know prior to examination which type of insurance will apply or with whom our office will be able to file a claim for you. We make every effort to determine as much information for you in advance.

I understand the paragraphs above and authorize Corridor Family Eyecare to file a claim on my behalf and I understand that I am responsible for any co-pays, co-insurance, or deductible not yet met.

Patient Name (Please Type):

Patient/Guardian Signature

Type your full name for your digital signature

Date

Please Read the Following:

Digital Retinal Imaging

During a comprehensive eye exam, our doctors need to evaluate the overall health of your eye. With OptomapⓇ Retinal Exam, we can screen for retinal complications including Macular Degeneration, Glaucoma, and retinal holes or detachments.

This screening procedure can also detect systemic problems unrelated to the eye that may show signs in the retina such as Diabetes, Hypertension, Cancer/Tumors, Autoimmune disorders, and others, earlier than possible with traditional methods.

The OptomapⓇ Retinal Exam

It is as fast as taking a picture.
DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, eliminating a 30-minute wait and avoiding side effects such as blurry vision and light sensitivity.
Saved in your file, enabling our doctor to make important comparisons during your annual eye exam.

There will be a $34.00 charge for the OptomapⓇ Retinal Exam.

NOTE- * Beginning the summer of 2026, this exam will be required for ALL patients seen at Corridor Family Eyecare. This change is to help our Doctor closely monitor any and all potential ocular diseases/conditions that would be missed otherwise. We appreciate your understanding and cooperation! If you have any further questions or concerns regarding this policy, please reach out to our office by phone call or text to communicate with a staff member who can help. *

Patient/Guardian Signature

Type your full name for your digital signature

Date

IMPORTANT-

Beginning 1/1/2026, our office will be charging a $25 fee for appointments canceled within 24 hours, and appointments which are missed without notification (No-Call-No-Show). We appreciate your understanding for our new change in policy. If you have any questions, please contact our office by Text or email. We look forward to seeing you for your appointment!

I have read and I understand/accept the policy listed above

I have read all policies in this form and accept any/all potential charges associated with my visit to Corridor Family Eyecare.

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