Return Patient Information Form

*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.

First Name

Middle Initial

Last Name

Date of Birth

Height

Feet and Inches

Weight

Lbs

Phone Number

no spaces or dashes

Address

House Number and Street Name

Apt/Suite

City, State

Zipcode

Insurance Company Name

Member ID#

Policy Holder's Information

Name and DOB

Insurance Cards Please upload front and back of card(s)

Add file

Please upload a file

Please list current Medications. Include any oral contraceptives, over-the-counter, and/or herbal.

Medication List Upload med list here, if you choose

Add file

Please upload a file

If yes, Please list them here:

Review of Systems

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

Same as last visit, no changes in diagnoses

if any changes please check any boxes below that apply

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

None

Muscular/Skeletal

Arthritis

Osteoarthritis

Fibromyalgia

Muscular Dystrophy

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/Lymohatic

Anemia

Large-Volume Blood Loss

Ulcer

Hypercholesteremia

None

Allergic/Immunologic

Drug Allergies

Environmental Allergies

Rheumatoid Arthritis

Lupus

Sjogren's Syndrome

None

Other

If other, please list here

Social History

Tobacco Use

Current Everday

Current Some Days

Quit Smoking

Never a Smoker

Alcohol Intake

Frequently

Socially

Rarely

Quit Drinking

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 before 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 Eye Care on my behalf for any services provided to me by the office.

Signature of Patient/Guardian

Type full name for Electronic Signature

Relationship to Patient

If signing as Parent/Guardian

Date

Please read the following:

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

Is as fast as taking a picture.
DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, potentially 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.

Signature of Patient/Guardian

Type full name for electronic signature

Relationship to Patient

if signing as Parent/Guardian

Date

HIPAA

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

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

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

Signature of Patient/Guardian

Type full name for electronic signature

Relationship to Patient

if signing as Parent/Guardian

Date

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

Phone Number

no spaces or dashes

Name

First and Last

Relationship

Phone Number

no spaces or dashes

Your information will be encrypted.