Borel Eye Doctors Patient Form

Date:_________________ Marcie Arnesty, O.D. Emily Gorski, O.D. Terri Mark, O.D. WELCOME TO OUR OFFICE Tim Mock, O.D. Please complete this Patient Information and Health History Form

(Circle one) Dr. Mr. Mrs. Ms. First Name____________________________ Last Name______________________________ MI_____ Birthdate_____________ Address _______________________________________________________ City_______________________ St _____ Zip_________ Email ________________________________ Sex M or F or X Home Phone (_____) ______-_________ Cell Phone (_____) ______-_________ Occupation _________________________ Employer ________________________________________ Spouse or DP ________________ their Occup ________________ their Employer _______________ OR (under age 18) Parent / Guardian Name_________________________________________________ Whom may we thank for referring you? _____________________________________________________ I. INSURANCE AND PRIVACY PRACTICES: Please provide all benefit Info prior to seeing Dr Insurance: q VSP q Eyemed q Medicare 65+ q Other: ______________________________ Member Name: _________________________ Member ID# ________________________________ Secondary Insurance: ______________________ Member ID# ____________________________ Relationship to Primary Insured: q Self q Spouse or DP q Child q Double Coverage Please provide any and all benefit cards to receptionist

Privacy Practices Acknowledgement: I have received the Notice of Privacy Practices and the opportunity to review it.

Patient Signature: ____________________________________________

Preferred Method of Communication: For all appointment and glasses or contact lens notifications I prefer: q Text me at cell above q Email me at above address OR Call # ___________________

II.

REASON FOR VISIT: Check all reasons for wanting your eyes examined that apply q Routine Exam q Light Sensitivity q Wearing Contacts- having problems q Double Vision q Distance Vision Blurred q Lost or Broken Glasses q Close vision blurred q Interested In Contact Lenses q Injured, infected or red eye q Suggested by physician q Watery, Itchy or burning eyes q Eye fatigue or headaches q Low on contact lens supply q Eye pain or discomfort q Eyelid swelling or twitching q Floaters, flashes or spider webs q Loss of vision q Interested in Lasik Surgery q Dry Eyes q Other:

When was your last eye exam? ________________________________________________________ List activities, hobbies, and amount of time on computer (or digital device) to consider for your needs:

____________________________________________________________________________

____________________________________________________________________________

III. EYE/ MEDICAL HEALTH & HISTORY: Indicate the following condition(s) which pertain to you or immediate

family by circling those that apply and to whom‌ (i.e. self, mother, father, grandmother, grandfather, aunt, etc)

CONDITION

WHO

Glaucoma Cataracts Eye turned in / out Detached retina Retinitis pigmentosa Eye surgery (including Lasik) High Blood Pressure

CONDITION

WHO

Diabetes Eye Infections Hardening of arteries Lazy eye/ eye exercises Allergies Abnormal thyroid High Cholesterol

CONDITION

WHO

Macular Degeneration Cancer Currently Pregnant Tumors of eye or brain Growths on eye (stye, etc) Other Special Needs

Are you currently seeing a physician for any health problems? YES NO (circle one) Do you smoke tobacco products? YES NO Are you a former smoker? YES NO Are you currently taking any medications? YES NO (circle one)

If yes, please list name of meds and reason (include birth control, aspirin, etc) __________________________________________________________________________________ Are you allergic to any medications or novocaine? YES or NO (circle one)

Please list: ________________________________________________________________ IV.

CONTACT LENS HISTORY: Check if you: q Currently wear contacts or q Worn in the past q Soft Disposable: q Daily q 2-Week q Monthly q Extended Wear q Toric q Multifocal or Bifocal q Monovision q Gas Permeable q CRT / Hybrid Hours per day: ______ Contact Lens Brand: ______________________

________________________________________ SOLUTIONS: Current Solutions: ___________________________ Any adverse reactions to solutions? YES NO If yes, which?______________________ V.

INSURANCE BILLING AND PAYMENT: Please review our financial policy listed below PAYMENT IN FULL IS DUE UPON COMPLETION OF EXAMINATION TODAY. PLEASE INDICATE METHOD OF PAYMENT.

q Vision or Medical Insurance (see front)

q Cash

q Check

q Credit Card

Borel Eye Doctors, Optometry With Vision, is committed to providing you with the best possible care. We are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please inquire with any concerns about our fees, our Financial Policy or your responsibility.

We will not become involved in disputes between you and your insurance company regarding required co-payments, application of fees toward deductibles, covered charges, secondary insurance, usual and customary fees, etc.- other than to supply the factual information as necessary. YOU are responsible for knowing what your insurance covers and the timely payment of your account. VSP, Eyemed Access, Medicare and other medical insurances require patients to pay for any co-payment(s) / overage(s) at the time of service.

Your signature is required below as acknowledgment of: 1) our Insurance Billing and Payment Financial Policy and 2) All of the information provided in this form is correct and complete, to the best of your knowledge.

Signature / Account Responsible _________________________________ Date ____________ Thank you. Please return this form to the receptionist.