Welcome to Our Office Name* First Last Date* MM DD YYYY Brithday* MM DD YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Primary Phone*Work PhoneCell PhoneEmail SS#OccupationGender*MaleFemaleMarital Status*SingleMarriedOtherSpouse's Name First Last If studentWhat grade?What school?Parent's Name First Last Last Eye ExamHow many years ago?Who were you examined by?Last EyeglassesHow many years ago?Last Physical ExamHow many years ago?Who were you examined by?Medical HistoryDo you take any medications or vitamins?*YesNoPlease list: Are you allergic to any medications?*YesNoPlease list: Do you or a family member have (sugar) Diabetes?*YesNoDo you have Arthritis?*YesNoDo you or a family member have High Blood Pressure?*YesNoDo you have Thyroid Dysfunction?*YesNoDo you or a family member have Heart Troubles?*YesNoDo you have any other medical conditions?*YesNoPlease list: Have you or a family member had cancer?*YesNoDo you currently smoke?*YesNoEye Health HistoryDo you or a family member have Glaucoma?*YesNoDo you or a family member have Cataracts?*YesNoDo you or a family member have Macular Degeneration?*YesNoHave you ever had eye surgery?*YesNoDo you or a family member have a lazy eye or eye turn?*YesNoDo you have problems with dry eye or tearing?*YesNoDo you wear or are you interested in contact lenses?*YesNoDo you suffer from eye allergies?*YesNoWhat is the reason for today’s visit?Insurance/Release of InformationDo you have routine vision insurance?*YesNoPlease list:Do you have medical insurance?*YesNoPlease list:Primary Insured Name* First Last Primary Insured DOB* MM DD YYYY Address Check if different address The staff at Shore Family Eyecare will be happy to submit to your insurance for your visit. It is your responsibility to know if your insurance covers the type of office procedures performed and whether referrals are necessary. I am responsible for all fees, referrals, co-pays, deductibles and non-covered procedures and devices provided. I authorize Shore Family Eyecare to submit to my insurance and assign the benefits to be directly paid to the doctors of Shore Family Eyecare when applicable. I understand that Shore Family Eyecare is fully compliant with HIPAA regulations and privacy issues. I request my professional records/reports only to be released to Shore Family Eyecare when necessary and to release my records to other doctors/professionals who may provide care for me in the future.Signature*Date* MM DD YYYY How did you hear about Shore Family Eyecare? Dietrich Opticians NJ Commission for the Blind Pediatrician Newspaper Internet/Website School Nurse/OT Eye Doctor Family Friend Insurance Thank you for your confidence
