Intake Form Step 1 of 4 25% Insurance InformationThank you for scheduling an exam at our office! We look forward to meeting you, but need a little more information about your upcoming visit before we are ready to see you. This form contains confidential information and is delivered to your doctor through a secure internet connection. Please fill it out as soon as possible. IF WE DO NOT RECEIVE THIS COMPLETED FORM BEFORE YOUR SCHEDULED APPOINTMENT TIME, WE MAY NEED TO RESCHEDULE YOUR APPOINTMENT TO ANOTHER DATE/TIME. If you have any questions, feel free to call us at 502-996-7450.Patient NameFirst name Last name What are we seeing you for : Glasses Exam Contact Exam Diabetic Exam Eye Infection Eye Injury Other Will You Be Using Insurance Yes No (please complete all applicable info below to avoid your appointment being delayed or rescheduled)Vision Insurance : Avesis Davis EyeMed Passport Spectera Tricare VSP Other Subscriber Name: First Last Date of Birth: Last 4 SSN: Member ID: Primary Medical Insurance: Aetna Anthem Humana Medicare United Health Care Other Subscriber Name: First Last Date of Birth: Member ID: Group ID: Secondary Medical Insurance (if applicable): Aetna Anthem Humana Medicare United Health Care Other Subscriber Name: First Last Date of Birth: Member ID: Group ID: DemographicsDateName First Last Address Street Address City State / Province / Region ZIP / Postal Code Sex: M F Birthdate: Age: Height : ft and inWeight : lbsPhone (Home):Phone (Cell):Email Employed: Yes No Occupation: Primary Physician: City/Group: Last Visit (Approx): Previous Eye Doctor: City/Group: Last Visit (Approx): Do You Wear Glasses : All the time Driving Only Reading Only Never Do You Wear Contacts : All the time Occasionally Never Have You Ever Had: Lazy Eye Eye Injury Eye Surgery Eye Infection Do You Routinely Experience or Currently Have : Vision Loss Blurry Vision Double Vision Dryness Redness Crusting/Discharge Itchy Eyes Burning Eyes Watery Eyes Light Sensitivity Eye Pain Stye/Sties Floaters Cataracts Glaucoma Macular Degeneration Poor Color Vision Medications You Are Currently Taking (List): Add RemoveAllergies to Medications (List): Add RemoveOther Allergies (List): Add RemoveDo You Have : Colitis Chron’s Disease Chronic Fatigue Eczema/Psoriasis Headaches Seizures Multiple Sclerosis Diabetes Thyroid Dysfunction Asthma Emphysema Heart Disease High Cholesterol High Blood Pressure Seasonal Allergies Sinus Problems Lupus Arthritis Blood Disorder Fibromyalgia Kidney Problems Family History :Cataracts Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherMacular Degeneration Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherGlaucoma Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherRetinal Detachment Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherCrossed/Lazy Eye Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherCancer Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherDiabetes Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherHeart Disease Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherHigh Blood Pressure Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherArthritis Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherThyroid Disease Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOtherColor Vision Problems Yes No Unknown MomDadMat GMMat GFPat GMPat GFBrotherSisterOther Notice of Privacy Practices Derby City Eye Care HIPAA Policy I have been offered and/or received the notice of privacy practices for Derby City Eye Care.Name First Last Date MM slash DD slash YYYY Digital ConsentBy including my name below, I authorize Derby City Eye Care to communicate with me via mobile phone, text message, email, and any other kind of online or digital communication. I also authorize Derby City Eye Care to provide me with digital copies of my eyeglass prescription, contact lens prescription, and medical records upon my request. I understand that digital copies are not encrypted and agree to assume the risks associated with receiving them in this manner. I also understand that I may request paper copies of these materials at any time.Name First Last Date MM slash DD slash YYYY Number
