Male    Female









Single    Married   Widowed  
 Separated    Divorced




















English    Spanish
American Indian or Alaska Native  
 Asian    Black or African American  
 Hispanic    White  
 Native Hawaiian/other Pacific Islander
 Hispanic or Latino
 Not Hispanic or Latino
 Native Hawaiian/other Pacific Islander








 Spouse    Parent    Other






 Spouse    Parent    Other


ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with    and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all the information necessary to secure the payment of benefits. I authorize the use of this signature on all the insurance submissions.

Relationship  

Date             

 











EMERGENCY CONTACT Specify someone who does not live in your household.
















Yes         No










PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE ANY OF THE FOLLOWING:
Bloodshot Eyes
Yes         No
Blurred Vision - Distance
Yes         No
Blurred Vision - Near
Yes         No
Burning Eyes
Yes         No
Cataracts
Yes         No
Color Vision, Poor
Yes         No
Crossed Eyes
Yes         No
Discharge From Eyes
Yes         No
Dizzy Spells
Yes         No
Double Vision
Yes         No
Dry Eyes
Yes         No
Eye Infection
Yes         No
Eye Injury
Yes         No
Eye Strain
Yes         No
Fainting Spells, Blackouts
Yes         No
Floaters or Spots
Yes         No
Glaucoma
Yes         No
Headaches
Yes         No
Itching Eyes
Yes         No
Light Sensitive
Yes         No
Loss of Vision
Yes         No
Migraine Headaches
Yes         No
Night Vision, Poor
Yes         No
Red Eyes
Yes         No
Seeing Halos
Yes         No
Seeing Flashes
Yes         No
Temporary Loss of Vision
Yes         No
Twitching Eyelid
Yes         No
Poor Vision
Yes         No
Watering Eyes
Yes         No




PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE ANY OF THE FOLLOWING. ALSO PLACE MARK IN THE APPROPRIATE COLUMN TO INDICATE IF A BLOOD RELATIVE HAS HAD ANY OF THE FOLLOWING PROBLEMS:

                                                YOURSELF         BLOOD RELATIVES
AIDS/HIV
Yes    No          Yes    No
Arthritis
Yes    No          Yes    No
Artificial Heart valve
Yes    No          Yes    No
Artificial joints
Yes    No          Yes    No
Asthma
Yes    No          Yes    No
Blindness
Yes    No          Yes    No
Cancer
Yes    No          Yes    No
Cataracts
Yes    No          Yes    No
Chemical Dependency
Yes    No          Yes    No
Diabetes
Yes    No          Yes    No
Drug Sensitivity
Yes    No          Yes    No
Emphysema
Yes    No          Yes    No
Epilepsy
Yes    No          Yes    No
Glaucoma
Yes    No          Yes    No
Hay Fever
Yes    No          Yes    No
Heart Condition
Yes    No          Yes    No
High Blood Pressure
Yes    No          Yes    No
Lupus
Yes    No          Yes    No
Migraine Headaches
Yes    No          Yes    No
Pacemaker
Yes    No          Yes    No
Poor Color Vision
Yes    No          Yes    No
Retinal Disease
Yes    No          Yes    No
Rheumatic Fever
Yes    No          Yes    No
Shingles
Yes    No          Yes    No
Skin Conditions
Yes    No          Yes    No
Stroke
Yes    No          Yes    No
Thyroid Conditions
Yes    No          Yes    No
Tuberculosis
Yes    No          Yes    No
Turned Eye
Yes    No          Yes    No
Tobacco Use
 None  Former Smoker
 Current Everyday Smoker
 Current Someday Smoker
Alcohol Use
 None  Social Use Only
 1-2 Drinks Daily
 Above Average Use
 Alcohol Dependence
Are you pregnant?
Yes    No          Yes    No
Number of Children

MEDICATIONS
List medications you are currently taking, including eye drops:





ALLERGIES List your allergies to medications or other substances:


ACKNOWLEDGEMENT OF PRIVACY PRACTICES
I acknowledge that I have received, read and understand the Notice of Privacy Practices containing a description of the uses and disclosures of my health information. I understand that this information can and will be used to:
1. Conduct, plan and direct my treatment and follow-up among multiple providers who may be involved in that treatment directly.
2. Obtain payment from third-party payers.
3. Conduct normal healthcare operations such as quality assessments and physician certifications.
I understand that Eye Care Center of Colorado Springs, PC has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy.

Patient or Guardian Signature Date
OFFICE USE ONLY
I attempted to obtain the patient’s signature in acknowledgement but was unable to do so as documented below:

Date Initials
Reason
Please fill in the matching text and submit the form below.