Rockledge Patient Information Form Name First Middle Last Date MM slash DD slash YYYY Parent/Guardian Ethnicity Gender Male Female Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Age Birthdate MM slash DD slash YYYY SS# Home PhoneWork PhoneOtherCell(We use text messaging for appointment reminders & to let you know when glasses or contacts are ready)Employer Occupation Email(We will send your exam results. Please send response when received) Vision Insurance Name Policy# Medical Insurance Name Policy# Policyholder Name First Middle Last SS# Who may we thank for referring you Optomap Optomap digital retinal imaging is the standard of care at Family Vision Center and is performed on every patient, every year prior to seeing the doctor for an eye exam. The cost is $39.00 and is not covered by insurance plans. The optomap is advanced technology that takes and ultra-widefield 200-degree digital image of your retina. This is a digital image of the back of your eye which is a great first step in checking the overall health of your eyes. The advanced technology allows the doctors to see far more of your retina than is possible using standard technology. . Dilation We may need to install drops to examine the inner wall of your eyes. These drops may cause some sensitivity to light and blurred vision. May we use diagnostic drops to dilate your eyes? Accept Decline Notice of Privacy Practices I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care A source of information for applying my diagnosis and surgical information to my bill A means by which a third-party payer can verify that services billed were actually provided And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I have been provided with a Notice of Privacy Practices that gives a more complete description of information uses and disclosures as well as a description of my privacy rights. I understand that I can review the notice prior to signing this acknowledgement. I understand that the organization reserves the right to change their notice and practices and will provide me a copy of any revised notice. By signing below you acknowledge that a full copy of our HIPAA form is available to you on our websiteEmergency Contact Name First Last PhoneWho may we share your information with First Last We reserve the right to charge $50.00 for appointments missed without 48 hours notice. Accounts over 90 days past due are subject to a $25.00 late fee. In the event my account is referred to collections, I agree to pay all costs of collection, including but not limited to reasonable attorney’s fees. I have reviewed and understand the information contained on this form. Patient SignatureWitnessEye Health HistoryLast Eye Exam Glasses Contact Lenses(type) Injuries Yes No If yes, please specify Right eye Left eye if any, please describe Prosthesis Yes No If yes, please specify Right eye Left eye if any, please describe Cataracts Yes No If yes, please specify Right eye Left eye if any, please describe Glaucoma Yes No If yes, please specify Right eye Left eye if any, please describe Retinal Injuries\Issues Yes No If yes, please specify Right eye Left eye if any, please describe Lazy Eye Yes No If yes, please specify Right eye Left eye if any, please describe Macular Drusen Yes No If yes, please specify Right eye Left eye if any, please describe Double Vision Yes No If yes, please specify Right eye Left eye if any, please describe Corneal Scar Yes No If yes, please specify Right eye Left eye if any, please describe Keratconous Yes No If yes, please specify Right eye Left eye if any, please describe Dry Eye Yes No If yes, please specify Right eye Left eye if any, please describe Nevus Yes No If yes, please specify Right eye Left eye if any, please describe Floaters Yes No If yes, please specify Right eye Left eye if any, please describe Medical HistoryPlease check off any conditions you have hadCardiovascular Heart Cholesterol Hypertension Stroke If any, please describe: Constitutional Fever Weight Loss If any, please describe: Endocrine Diabetes Thyroid Condition If any, please describe: Gastrointestinal Acid Reflux Ulcers Hepatitis If any, please describe: Genitourinary Bladder Menopause Prostate If any, please describe: ENT Ear Nose Throat If any, please describe: Hematologic, Lymphatic Anemia Cancer Sickle Cell If any, please describe: Immunological Herpes Simplex Shingles HIV If any, please describe: Integumentary Acne Rosacea Lupus If any, please describe: Musculoskeletal Arthritis Osteoporosis If any, please describe: Neurological Migraine Multiple Sclerosis Parkinsons If any, please describe: Psychiatric Anxiety Dementia Depression If any, please describe: Respiratory Asthma Emphysema Tuberculosis If any, please describe: Reproductive Pregnancy Menopause If any, please describe: Cancer or other medical problemsEye Surgeries Family Health HistoryCrossed Eye Yes No If yes, please indicate family member Lazy Eye Yes No If yes, please indicate family member Blindness Yes No If yes, please indicate family member Glaucoma Yes No If yes, please indicate family member Diabetes Yes No If yes, please indicate family member Other Eye Disease Yes No If yes, please indicate family member Current Eye Medications Current Medications Drug Allergies Social HistorySmoker Yes No Alcohol Yes No Drugs Yes No Pharmacy Name Location Primary Care Physician