Download Patient Information - clark eye care center

Welcome to the office of
Dr. Richard K. Clark, Board certified optometric physician
Dr. Sean G. Walton, Board Certified Optometric Physician
Patient Information
Date __________________________
Patient name: Last _____________________________________________ First ___________________________________________ MI ___________
Social security #: ______________________________________ Birth date: ________________________________ Age: _________
Sex: ______ male ______ female
Driver's License #: _____________________________________ Height: ___________ Weight: ____________
Home phone: _______________________________ Work phone: _____________________________ Cell phone: _______________________________
Address: ___________________________________________________________ City: _____________________ State: ___________ Zip: ______________
E-mail address: ______________________________________________________
May we contact you by email for appointment reminders?
Yes
No
Text?
Yes
No
How did you hear about Clark Eye Care? ___ Yellow pages ___ Saw sign ___ Referral ___ Web Site ___Other ____________
If referral, whom may we thank? ____________________________________________________________________________________
Guardian name: (person responsible for this account if patient is a minor)
Relationship to patient: ______________________________________________
Last _____________________________________________ First ___________________________________________ MI ___________
Social security #: ______________________________________ Driver's License #: __________________________________________
Employer/school: ______________________________________________________________
Birth date: ________________________________ Age: __________________ Sex: _________ male _________ female
Home phone: _______________________________ Work phone: _____________________________ Cell phone: _______________________________
Address: ___________________________________________________________ City: _____________________ State: ___________ Zip: ______________
E-mail address: ______________________________________________________________
Insurance Information
Vision Insurance Name: ___________________________________
Subscriber's Name: ____________________________________________
Subscriber's Social Security #: __________________________________ Subscriber's Birthdate: _________________________________
Member ID/Subscriber ID/Policy #: _________________________________________________
Primary Medical Insurance Name: _________________________________
Subscriber's Name: ___________________________________________
Subscriber's Social Security #: __________________________________ Subscriber's Birthdate: ________________________________________
Member ID/Subscriber ID/Policy #: __________________________________________________
Secondary Medical Insurance Name: ____________________________________________
Policy #:________________________________________
Personal Social history
Do you use tobacco products? ____ No ____ Yes: If yes, frequency? ___ Rarely ___ Moderate ___ Frequently ___ Heavy
Do you drink alcohol?
____ No ____ Yes: If yes, frequency? ___ Rarely ___ Moderate ___ Frequently ___ Heavy
Personal Medical History (Check those that apply to you :)
___ Diabetes
___ Lupus
___ Thyroid disease
___ Rheumatoid arthritis
___ Giant cell arteritis
___ Migraine headaches
___ Multiple Sclerosis
___ Sarcoidosis
___ Heart disease
___ Kidney disease
___ High blood pressure
___ Asthma/emphysema
___ Stroke
___ Cancer
___ Anemia
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___ Depression
___ Tuberculosis
___ HIV/AIDS
___ Lung disease
___ Other _____________________
Welcome to the office of
Dr. Richard K. Clark, Board certified optometric physician
Dr. Sean G. Walton, Board Certified Optometric Physician
Eye Health History
Check if you are experiencing the following:
___ bloodshot eyes
___ blurred vision
___ burning eyes
___ cloudy Vision
___ color vision
___ Crossed eyes
___ discharge from eyes
___ Dizzy spells
___ double vision
___ Dry eyes
___ eye infection
___ eye injury
___ Eye strain
___ fainting spells
___ Floaters/spots
___ headaches
___ itching eyes
___ Light sensitive
___ loss of vision
___ Migraine headaches
___ Night Vision, Poor
___ Peripheral vision loss
___ Red eyes
___ seeing halos
___ seeing flashes
___ temporary loss of vision
___ twitching eyelid
___ watering eyes
Date of your last eye exam: _______________________________________
Do you wear glasses?
____ No ____ Yes If yes, how old is your present pair? _____________________
Do you wear contact lenses? ____ No ____ Yes If yes, do you wear: ____ Soft ____ Gas permeable ____ Hard
Have you had previous eye disease, eye injury or eye surgery? ____ No ____ Yes If yes, explain:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Check if you have been diagnosed with:
___ Glaucoma
___ Amblyopia
___ Cataracts
___ Retina Detachment
___ Macular degeneration
___ Strabismus
___ Other __________________________________________________________________________________________________________________
Medications
Allergies
List any medications you are currently taking, including eye
drops:
List your allergies to medications and other substances:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Pharmacy Name______________________________________________
_________________________________________________________________
Phone (________)______________________________________________
Family Ocular/Medical History
Please note any blood relatives that have the following conditions:
___ Glaucoma
___ macular degeneration
___ Blindness
___ Retinal detachment
___ Cataracts
___ Eye disease (describe to dr.)
___ Misaligned eyes
___ Arthritis
___ Diabetes
___ Heart disease
___ Kidney disease
___ Thyroid disease
___ Cancer
___ Other ______________________________________________________
Relationship to you
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
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Welcome to the office of
Dr. Richard K. Clark, Board certified optometric physician
Dr. Sean G. Walton, Board Certified Optometric Physician
Personal review of systems
Physician’s Name ____________________________________________________________
Date of last visit ______________________________
Check those that apply to you:
Constitutional:
Genitourinary tract:
Neurological:
___ Weight loss/gain
___ Incontinence
___ Numbness/weakness
___ Chronic Fatigue
___ painful urination
___ Loss of memory
___ Fever/Chills
___ Difficult urination
___ Headache
___ Other______________________________
___ Frequent urination
___ Dizziness
___ Kidney disease
___ Seizures
Ears/nose/throat:
___ Other ______________________________
___ Other ______________________________
___ Loss of hearing
___Sinus Congestion
Hematological:
Psychiatric:
___Nose Bleeds
___ Low blood count
___ Depression
___Dry throat/Mouth
___ Easy bruising
___ Other ______________________________
___ Other______________________________
___ Bleeding problems
___ Anemia
Endocrine:
Vascular/cardiovascular:
___ Other ______________________________
___ Swollen Glands
___ Chest pain
___ Thyroid disease
___ Irregular heart beat
Allergy/immunity:
___ Other _____________________________
___ High blood pressure
___ Environmental allergies
___ Vascular disease
___ Seasonal allergies
Integumentary:
___ Other______________________________
___ hayfever
___ Skin disorders
___ Other ______________________________
___ Other _____________________________
Respiratory:
___ Asthma
Musculoskeletal:
Gastrointestinal:
___ Wheezing
___ Rheumatoid arthritis
___ Constipation
___ Chronic Bronchitis
___ Painful joints
___ Diarrhea
___ Shortness of breath
___ Muscle pain
___ Other _____________________________
___ Other ______________________________
___ Other ______________________________
Are you Pregnant or Nursing?
Are you diabetic?
Yes
Yes
No
No If Yes, How long have you been diabetic? ___________________ What is your A1C? ________________
What is the name and address of the doctor that follows your diabetes? _______________________________________________________
_______________________________________________________
When was your last diabetic exam? ___________________________________
Dilation
Our doctors strongly recommend that all patients receive a dilated eye examination every year. A dilated eye examination
allows the doctor to evaluate the health of the retina and the inside of the eye. This aids the doctor in determining diseases
such as macular degeneration, glaucoma, diabetic retinopathy, retinal holes and tears, cataracts and tumors of the eyes.
Please select one of the following boxes below.
I Agree to have my eyes dilated today and understand the importance of an annual dilated exam.
I Do Not wish to have my eyes dilated today. And, I release Dr. Clark/Dr. Walton from any liabilities
related to the failure to treat or diagnose any eye conditions due to the lack of diagnostic
information, which could have been obtained by these tests.
Eyewear Waiver/Refund Policy
Eyewear is a custom made product designed by your doctor and eye care professionals, especially tailored to each
individual patient’s needs. It is our policy that there will be NO refunds on custom-made eyewear, so please be certain that
the eyewear YOU have chosen is what you desire before payment has been made. If you are unhappy with your purchase, we
will be happy to make an exchange or issue store credit, within 30 days of your purchase date.
We require payment in-full for your eyewear order, before the order can be placed, unless other arrangements have been
made. So again, please be certain that the eyewear you have chosen is what you desire.
Any orders placed and not picked up within 30 days will be returned to stock – with NO refunds – unless other
arrangements have been made.
Signature ___________________________________________________ Date ______________________________
(Patient/Parent or Guardian if minor)
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Welcome to the office of
Dr. Richard K. Clark, Board certified optometric physician
Dr. Sean G. Walton, Board Certified Optometric Physician
Financial Policy
Your clear understanding of our financial policy is important to our professional relationship. Therefore, we wish to
clarify the following points:
1. I acknowledge that I am fully responsible for all costs incurred during my treatment at Clark Eye Care Center.
2. Payment is due at the time of service.
3. I understand that as a service, Clark Eye Care Center will file my insurance claims, but they do require a copy of my
insurance card to insure accurate information for processing.
4. I authorize the physician to release any information required to process this claim.
5. I understand that my insurance is a contract between me and the insurance company and Clark Eye Care Center is
not a party to that contract. If my insurance company does not pay in a timely manner (60 days), I will be responsible
for payment of the charges incurred.
6. I agree to pay Clark Eye Care Center (in full) within 30 days of notification of nonpayment by my insurance carrier.
7. I understand that I will be responsible for services deemed “not medically necessary” by my insurance company.
8. Parents and guardians are responsible for full payment on unaccompanied minors.
9. I agree that payment of insurance benefits be made on my behalf to Clark Eye Care Center for any services
furnished me by Clark Eye Care Center.
10. I understand that a Collection Agency may be used to collect unpaid balances. I further agree to pay any and all
legal and collection costs on my account.
11. I understand there is a $25.00 service fee for all returned checks.
Signature __________________________________________________
Date _____________________________
(Patient/Parent or Guardian if minor)
Vision Care Insurance vs. Medical Insurance
We often have patients that have both vision insurance (IE: VSP or Eyemed) and medical insurance (IE: BCBS, Aetna or
Medicare). They are very different in terms of the services they cover, and it's important for our patients to understand
these differences.
Vision Insurance is designed mainly to cover determining a prescription for glasses, to help pay for glasses or contact
lenses, and to cover a yearly routine evaluation of the health of the eyes in a healthy patient that has no particular
problems or symptoms. It is not equipped to deal with and does not usually cover medical conditions, injuries, and/or
treatments.
Medical insurance is designed to cover you when you have a medical problem, including one that affects your eyes. Medical
insurance does not cover routine services or examinations for glasses, or routine vision problems such as nearsightedness,
farsightedness and astigmatism. Those are only covered by your vision insurance.
When a medical diagnosis or medical condition is present that affects your eyes, such as high blood pressure, high
cholesterol or diabetes, or you have an eye disease or problem such as an infection (pink eye), dry eyes, allergies or
cataracts, we must file the claim with your medical insurance, and the co-pays and deductibles for that insurance will apply.
Your vision plan does not cover these kind of problems. Our office does not make these rules, they are made by the
insurance companies, and we must comply with them.
There is often no way to know prior to your examination which type of insurance will be the right one to file your claim with.
We make every effort to join as many insurance panels, both medical and vision, as we can for your convenience. If we are on
your insurance company's panel we will file those claims for you. In the event that we do not accept your medical or vision
insurance we will provide you with an itemized receipt so that you may file a claim for reimbursement with your insurance
company yourself. If you have any questions, please let us know.
I understand the information I've just read about the difference between vision and medical insurance. I authorize Dr.
Clark/Dr. Walton to file my claim with the appropriate insurance based on the reason for my visit and the results of my
examination.
Signature:_____________________________________________________
(Patient/Parent or Guardian if Minor)
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Date:_____________________________