First Name: ______Last Name: ______Middle Initial: ____ Preferred Name: ______
Birth Date: ___/___/____ Social Security Number: ______Sex: M / F Marital Status: Single Married Other
Home Address: ______City: ______State: ______Zip: ______
Home Phone: ______Work Phone: ______Cell Phone: ______E-mail address: ______
Emergency Contact Name: ______Relation:______Phone: ______
Medical Insurance: ______Vision Insurance: ______
Insured’s Name (if different from patient): ______Insured’s Birth Date (if different from patient): ___/___/____
Insured’s Social Security Number (only needed if your insurance is Tricare): ______
How did you hear about our office?
Internet Drive By Insurance Postcard in Mail Radio Referred by:______Other______
Method of Payment for Today’s Services: Cash Check Visa MasterCard
Payment is due on the date of service. If it is your understanding that your insurance will cover all charges for your visit, please confirm this with the front office associate before your examination.
NOTICE OF PRIVACY PRACTICES: I acknowledge that I have been offered a copy of Sparks Eye Care, LLC statement on HIPAA privacy practices
AUTHORIZATION TO RELEASE INFORMATION: I/We hereby authorize Sparks Eye Care, LLC to release any medical or incidental information that may be necessary for medical benefit or in processing applications for financial benefit. This includes but is not limited to other health care providers including my primary care physician, optical laboratories, my insurance company, Rehabilitation Services, Social Security Administration, and Worker’s Compensation.
INSURANCE CLAIMS: Sparks Eye Care, LLC may file by mail, fax, or telephone data to insurance companies assisting in the payment of fees. As required, Sparks Eye Care, LLC may use personal or medical information to assist in compliance issues, medical or peer review, insurance surveys, or other ways that are deemed by Dr. Sparks necessary for my medical management or as required by contractual agreements between Sparks Eye Care, LLC and other third party companies. Sparks Eye Care, LLC is not responsible for how other companies or agencies use my personal or medical information.
CONSENT FOR TREATMENT: I/We hereby authorize Sparks Eye Care, LLC to administer diagnostic and medical procedures as may be necessary for proper health care. In accordance with the Health Insurance Portability and Accountability Act, I authorize Dr. Sparks and/or any member of his staff to coordinate my medical care with other healthcare professionals, insurance companies and/or my immediate family members (i.e. spouse, parents, children). I understand that my eyes may be dilated during my examination, and I understand that dilation of my eyes may interfere with my ability to drive safely. I acknowledge that it is my responsibility to arrange for transportation after my examination is completed if I feel that I cannot safely operate a motor vehicle.
OFFICE POLICY ON PAYMENT: Payment is due on the date of service. I understand that I am responsible for payment of all charges. As a courtesy, my insurance may be billed for me. I authorize insurance benefits to be paid directly to the provider. It is my responsibility to pay any deductible, copay or any other balance not paid by my insurance company. My account will be considered to be delinquent if it is more than 60 days overdue. A fee of $25.00 will be charged for all returned checks.
GLASSES PURCHASES: All glasses purchases are final, and there are no refunds for any reason. There are no exceptions to this policy. This is due to the fact that spectacle lenses cannot be re-used once they are cut by the optical laboratory for a specific frame. If a prescription received from Sparks Eye Care is used to purchase glasses at another establishment, Sparks Eye Care does not warranty the glasses in any way.
CONTACT LENS FITTING & EVALUATION: The contact lens fitting and evaluation process requires at least two appointments. I understand that if I do not return for the follow-up appointment within one month of the initial appointment, the contact lens fitting and evaluation process will be terminated, and I will not receive a contact lens prescription. I also understand that any contact lens fees already paid will not be refunded.
VISION PLAN COVERAGE: I/We understand that only one vision plan may be used for exam/materials per visit-per patient and that the vision plan to be used must be chosen before the exam occurs and can not change at a later date.
TELEPHONE CORRESPONDENCE: Sparks Eye Care, LLC may contact me at the phone number(s) that I have provided. Sparks Eye Care, LLC may leave a telephone message on my answering machine or with anyone else in the household for me regarding confirmation of eye examination appointments, availability of eyeglasses / contact lenses for pick-up, delinquent account balances, etc.
RECORD RETENTION: This office maintains your records for at least five years from the last date of patient encounter. After that time, the office may destroy your records in a manner which protects patient confidentiality.
SIGNATURE: ______DATE: ______
PAST PERSONAL HISTORY
MEDICATIONS: Please list all medications and eye drops that you are currently taking:
______
______
______
ALLERGIES: Please list all known medication allergies and environmental/other allergies:
______
______
______
PRIMARY CARE PHYSICIAN INFORMATION
Name ______
Phone Number ______
When and where was your last physical exam? ______
When and where was your last EYE exam? ______
FAMILY HISTORY SOCIAL HISTORY
Please note any family member with the following Please check the substances you use and consume and also please
Diseases/conditions: M-mother F-father S-sister B-brother indicate hobbies, interests, and occupation:
GM-grandmother GF-grandfather
Yes No Family Member Yes No
Hypertension □ □ ______Alcohol □ □ Quantity: ______per week
Diabetes □ □ ______Drugs □ □ Quantity: ______per week
Cancer □ □ ______Tobacco □ □ Quantity: ______per week Blindness □ □ ______
Cataracts □ □ ______
Glaucoma □ □ ______
Macular □ □ ______
Degeneration
Hobbies/Interests:______
Occupation: ______
Glasses: Do you currently wear glasses? Y N
Contact Lenses: Do you currently wear contact lenses? Y N
REVIEW OF SYSTEMSCheck the symptoms and/or conditions you currently have or have had in the past.
Ocular/Eye Problems / YES / NO / Gastrointestinal Problems / YES / NO
Macular Degeneration / □ / □ / Colitis / □ / □
Glaucoma / □ / □ / Chron's disease / □ / □
Cataracts / □ / □ / Ulcers / □ / □
Crossed Eyes / □ / □ / Musculosketal Problems
Distorted Vision (Halos) / □ / □ / Ankylosis spondylitis / □ / □
Excessive Glare at Night / □ / □ / Fibromyalgia / □ / □
Dryness / □ / □ / Muscular Dystrophy / □ / □
Excess Tearing/Watering / □ / □ / Osteoarthritis / □ / □
Eye Pain or Soreness / □ / □ / Cardiovascular Problems
Fatigue/Tired Eyes / □ / □ / Vascular disease / □ / □
Inflammatory disorder / □ / □ / Stroke / □ / □
Light Sensitivity / □ / □ / Congestive heart failure / □ / □
Burning / □ / □ / Heart Disease / □ / □
Infection of Eye or Lid / □ / □ / High Blood Pressure / □ / □
Itching / □ / □ / Constitutional Problems
Lazy Eye / □ / □ / Fatigue / □ / □
Blurred Vision / □ / □ / Develop. Disability / □ / □
Mucous Discharge / □ / □ / Psychiatric Problems
Redness / □ / □ / Depression / □ / □
Eye Infection or Disease / □ / □ / Cancer
Trauma to the Eyes / □ / □ / Breast / □ / □
Ocular Surgery / □ / □ / Lung / □ / □
Patching / □ / □ / Prostate / □ / □
Allergy Immunologic Problems / Skin / □ / □
Drug allergies / □ / □ / Genitourinary Problems
Environmental Allergies / □ / □ / Prostate disease / □ / □
Lupus / □ / □ / STD / □ / □
Rheumatoid arthritis / □ / □ / Kidney Disease / □ / □
Reproductive / Ears, Nose, Mouth, Throat
Nursing Mother / □ / □ / Laryngitis / □ / □
Pregnant / □ / □ / Dry Mouth / □ / □
Endocrine Problems / Hearing Loss / □ / □
Insulin dependent diabetes / □ / □ / Hematologic/Lymphatic Problems
Non-insulin diabetes / □ / □ / Large volume blood loss / □ / □
Respiratory Problems / □ / □ / Anemia / □ / □
Emphysema / □ / □ / Skin Problems
Bronchitis / □ / □ / Rosacea / □ / □
Smoker / □ / □ / Psoriasis / □ / □
COPD / □ / □ / Eczema / □ / □
Asthma / □ / □ / Neurological
Cerebral palsy / □ / □
Multiple sclerosis / □ / □
Tumor / □ / □
Epilepsy / □ / □
Describe all serious illnesses, injuries and surgeries not listed above:
______
______