New Patient Form

New Patient Form

New Patient Form

New Patient Form

NEW PATIENT QUESTIONNAIRE

Full Name:

Preferred Phone:

Date of Birth:

SSN:

Other Phone:

Address:

City:

State:

Zip:

Email:

Gender:

Guardian (if applicable):

Occupation:

How did you hear about us?

If referred, who may we thank?

Status:

Race/Ethnicity:

Preferred Language:

Primary Care Physician/Office:

Date of last visit:

Please check appropriate answers and fill in blanks:

Constitutional

Fever, Fatigue Syndrome

Cancer

Ear, Nose, Mouth, Throat​​​​​​​

​​​​​​​Dry Throat/Mouth

Hearing Loss

Sinusitis

Neurological​​​​​​​

Seizures/Epilepsy

CVA/Stroke

Migraines

Tumor

Multiple Sclerosis

Psychiatric

Anxiety/Depression

Bipolar Disorder

Vascular/Cardiovascular​​​​​​​

Heart Disease

High Blood Pressure

Congestive Heart Failure

Respiratory​​​​​​​

Asthma

Sleep Apnea

Emphysema

Chronic Bronchitis

Gastrointestinal

Acid Reflux

Crohn’s Disease

Genitourinary​​​​​​​

Pregnant/Nursing

Sexually Transmitted Disease

Prostate disease

Bones/Joints/Muscles​​​​​​​

Arthritis

Osteoporosis

Muscle/Joint Pain

Integumentary​​​​​​​

Shingles/Herpes Zoster

Cold Sores/Herpes Simplex

Rosacea

Endocrine​​​​​​​

Type 1 Diabetes

Type 2 Diabetes

Thyroid Dysfunction

Lymphatic/Hematologic​​​​​​​​​​​​​​

High Cholesterol

Anemia

Hepatitis

Allergic/Immunologic​​​​​​​

Environmental Allergies

Sjogren’s Syndrome

If you have a condition not listed, please explain and LIST ANY MEDICATIONS you are taking (include oral contraceptives, aspirin, over-the-counter medication, vitamins, & home remedies):

Do you have any allergies to medication?

If yes, explain

Ocular History: Please check reason(s) for visit:

If you answered YES to any of the above, or have a condition not listed, please explain and LIST ANY EYE DROPS:

Family History
Please note any family history (parents, grandparents, siblings, children…living or deceased) for the following conditions:

Cancer

Diabetes

High Blood Pressure

Thyroid Disease

Heart Attack

Stroke

Cataract

Macular Degeneration

Glaucoma

Crossed Eyes

Amblyopia

Retinal Detachment

Social History
This information is kept strictly confidential.

Do you drive?

If yes, do you have visual difficulty when driving?

If yes, please describe:

Do you drink alcohol?

If yes, type/amount/how long

Do you use tobacco products?

If yes, type/amount/how long

Do you use recreational drugs?

If yes, type/amount/how long

What are your hobbies?

Glasses/Contact Lens History

Do you wear glasses?

Are they for:

Do you wear contact lenses?

Are they comfortable?

Type of contact lenses:

How often do you dispose of them?

Brand of contact lenses

How many hours a day do you usually wear them

NOTICE OF PATIENT PRIVACY RIGHTS, PROTECTION, AND RESPONSIBILITIES

SERVICES PROVIDED WITHOUT REFERRAL AUTHORIZATION
As a member of a vision care program, I acknowledge for today’s visit that I will assume full financial responsibility for services rendered to me if my vision insurance carrier denies or does not cover my claim for these services.

MEDICAL NECESSITY
If my insurance determines that a medical service and/or material are not covered, I acknowledge that I have been notified and will assume full responsibility for the service(s) and/or material stated below.

COPAYMENTS
I understand that I am responsible to pay all co-payments at the time of service, prior to leaving. Co-payments cannot be waived at any time by the provider of service or Clarity Eye Care.

DEDUCTIBLES
If my insurance determines that I have not met my deductible, I understand that I will be fully responsible for payment in a timely manner, no more than 30 days after I have been notified by insurance and/or provider. Yearly deductibles cannot be waived at any time by Clarity Eye Care.

PROFESSIONAL SERVICES AND MATERIALS
I understand that I am responsible for 100% of all professional fees rendered on the date of service. I understand that I am also required to make payment for at least 50% of materials at the time materials are ordered. If I am supplying my own frame, I understand that many plastic and metal products may weaken over time and I will not hold Clarity Eye Care or my insurance carrier responsible for accidental laboratory breakage. If I do not pick up my materials within 60 days from my initial order, my materials will be returned to the laboratory, and my initial deposit will not be refunded. If I am to receive contact lenses by mail, I understand that I am required to pay in full at time of service.

Our Patient Satisfaction Guarantee applies to single vision and progressive lenses. We use only premium single vision optics and premium progressive addition lenses, otherwise known as no line bifocals. Less than one percent of our patients have difficulty adapting to our premium progressive lenses. We will remake a non-adapt progressive lens or single vision lenses one time, in the same frame. If it is still unsatisfactory, we will replace it with a lined bifocal or a single vision lens, in the same frame. While we make every attempt to solve these rare issues, no refunds will be given in a case where a patient does not adapt to a progressive lens or single vision lens.

HIPAA
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which I have been provided a copy, that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly, obtain payment from third party payers, and conduct normal healthcare operation such as quality assessments and physician certifications.

AGREEMENT

Date

Guarantor/Patient Signature

Print Name

Roya1234 none 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 5:00 PM Closed Closed optometrist https://www.google.com/maps/place/Clarity+Eye+Care/@33.1730488,-96.7347637,17z/data=!4m7!3m6!1s0x864c15389f02a8ab:0x884b4b47541173b8!8m2!3d33.1730488!4d-96.732575!9m1!1b1 # https://www.facebook.com/clarityeyecaredtx/reviews/?ref=page_internal https://www.4patientcare.ws/wsv3pro/web/webschedulerv3.aspx?SessionID=15744754&Gcount=0 https://clarity.myclstore.com/Order/Welcome?aN=936884