Male    Female









Single    Married   Widowed  
 Separated    Divorced




























Yes         No

 







ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with    and assign directly to 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 HAD 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
Vision Poor
Yes         No
Watering Eyes
Yes         No




PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAD 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
Bleeding
Yes    No          Yes    No
Blindness
Yes    No          Yes    No
Cancer
Yes    No          Yes    No
Cataracts
Yes    No          Yes    No
Chemcial 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
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
Yes    No          Yes    No
Alcohol Use
Yes    No          Yes    No
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: