Patient Information Form

Patient Information

Patient First Name

Patient Last Name

Date of Birth

Street Address

City

State

Zip Code

Cell Phone

Home Phone

Email Address

Social Security Number

Gender

Patient Employer

Work Status

Full Time Part Time

Marital Status

Single Married Divorced Legally Separated Widowed

Language

Race

Ethnicity

Patient Contacts

Emergency Contact Phone Number

Emergency Contact Name

Primary Medical Insurance

Subscriber's Name

Relationship to Patient

Date of Birth

Social Security Number

Home Phone

Cell Phone

Subscriber's Employer

Work Phone

Insurance Provider

Secondary Medical Insurance

Subscriber's Name

Relationship to Patient

Date of Birth

Social Security Number

Home Phone

Cell Phone

Subscriber's Employer

Work Phone

Insurance Provider

Vision Insurance or Other Insurance

Subscriber's Name

Relationship to Patient

Date of Birth

Social Security Number

Home Phone

Cell Phone

Subscriber's Employer

Work Phone

Insurance Provider

Primary Care Physician Information

Primary Care Physician Name

Phone Number

Eye History

Date of last exam

Currently Wear Contacts?

Yes No

Currently Wear Glasses?

Yes No

If yes, brand?

Any eye surgery? List:

Reason for today's visit

Have you or a family member experienced, or been treated for,
any of the following? Circle all that apply.

Cataracts

Yes No

Relationship

Crossed Eye

Yes No

Relationship

Glaucoma

Yes No

Relationship

Lazy Eye

Yes No

Relationship

Macular Degeneration

Yes No

Relationship

Retinal Detachment

Yes No

Relationship

Medical History

Have you or a family member experienced or been treated for,
any of the following? Check all that apply.

AIDS/HIV

Yes No

Relationship

Allergies

Yes No

Relationship

Stroke

Yes No

Relationship

Arthritis

Yes No

Relationship

Thyroid Dysfunction

Yes No

Relationship

Asthma

Yes No

Relationship

Blood/Lymph Disorders

Yes No

Relationship

Blood/Skin Conditions

Yes No

Relationship

Diabetes

Yes No

Relationship

Ear, Nose, Throat Conditions

Yes No

Relationship

Gastrointestinal Conditions

Yes No

Relationship

Heart Disease

Yes No

Relationship

High Blood Pressure

Yes No

Relationship

High Cholesterol

Yes No

Relationship

Kidney Disease

Yes No

Relationship

Lupus

Yes No

Relationship

Neurological Conditions

Yes No

Relationship

Psychiatric Disroders

Yes No

Relationship

Seizures

Yes No

Relationship

Current Medications (prescription and over the counter and dosage)

Medication Drug Allergies

Weight

Height

Do you smoke?

Yes No

Are you Pregnant or Nursing?

N/A Yes No

Notes/Additional Information

Refraction Policy and Financial Responsibility Agreement

Most medical plans, including Medicare, do not cover refractions or routine eye examinations (when NO medical eye problem is known or suspected). If your examination includes refraction, there will be a $30.00 additional fee, since it is not a covered service.

I HEREBY AUTHORIZE THIS OFFICE TO APPLY FOR BENEFITS ON MY BEHALF FOR SERVICES RENDERED. I THOROUGHLY UNDERSTAND THAT MY INSURANCE IS AN AGREEMENT BETWEEN THE INSURANCE PROVIDER AND MYSELF, NOT BETWEEN THE INSURANCE PROVIDER AND THE MEDICAL OFFICE. IF AUTHORIZATION IS REQUIRED FROM MY PRIMARY CARE PHYSICIAN, I HAVE TO OBTAIN SUCH DOCUMENT(S) PRIOR TO MY VISIT. I THEREFORE AGREE THAT THE PAYMENTS FROM INSURANCE COMPANIES BE MADE TO OPTOMETRIC CONSULTANTS OF VIRGINIA, INC. (d.b.a. Eye & Vision Care). I ALSO UNDERSTAND AND AGREE THAT REGARDLESS OF MY INSURANCE STATUS, I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE OF MY ACCOUNT FOR MY MEDICAL SERVICES RENDERED. I CERTIFY THAT INFORMATION I HAVE REPORTED WITH REGARD TO MY INSURANCE COVERAGE IS CORRECT. I AUTHORIZE THE RELEASE OF ANY NECESSARY INFORMATION, INCLUDING MEDICAL RECORDS, TO DETERMINE INSURANCE BENEFITS TO WHICH I MAY BE ENTITLED.

I agree to these terms and conditions.

Date

Todays Date

Information Regarding Dilating Drops

Dilating drops are used to dilate or enlarge the pupils of the eye to allow the doctors at Optometric Consultants of Virginia, Inc. d.b.a Eye & Vision Care to get a better view of the inside of your eye.

Dilating drops blur the near vision. It does not affect the distance vision but light sensitivity can make driving difficult afterward. It is not possible for your optometrist to predict how much your vision will be affected. You may need a driver afterward.

Adverse reactions, such as acute angle-closure glaucoma, may be triggered by the dilating drops. This is extremely rare and treatable with immediate medical attention.

I hereby authorize Dr. Dimple Kapoor, O.D and/or associates, or such assistants as may be designated by her to administer dilating eye drops. The eye drops are necessary to diagnose my condition.

I agree to these terms and conditions.

Date

Todays Date

Notice of Privacy Practices

Our notice of privacy practice provides information about how we may use and disclose protected health information (PHI) about you. The notice contains a patient rights section describing your rights under the law. You have the right to review our notice before signing this consent. The terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of PHI about you for treatment, payment, and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosure we have already made in reliance on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I agree to these terms and conditions.

Date

Todays Date

Your information will be encrypted.