Patient Information Form - Ballard Vision Associates

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WELCOME TO BALLARD VISION ASSOCIATES
TODAY'S DATE: _____ / _____ / ______
PATIENT INFORMATION
Patient Name: ____________________________________________ Preferred Name?___________________________________
Address: ____________________________________ City: _____________________ State: _____ Zip: ____________________
Date of Birth: ____ / ____ / _____ Age: ____ Social Security #: _____-_____-______ Sex: [ ] Male
[ ] Female
Phone: Home: __________________________ Work: _________________________ Cell: _____________________________
E-mail Address: _______________________________________
(Kept absolutely confidential-used only for appt. reminders, etc.)
Occupation: __________________________________ Employer: ___________________________________________________
Marital Status: [ ]Single [ ]Married [ ]Divorced [ ]Widowed
Spouse's Name: _______________________ Occupation: ____________________ Employer: ____________________________
If Patient is a child- Name of Parent(s) Responsible:_______________________________________________________________
How did you first become aware of our practice?
[ ] Friend or Family (Name): _______________________________ [ ] Practice Website
[ ] Direct Mail
[ ] Medical Doctor (Name): _______________________________ [ ] Internet Search Engine
[ ] Yellow Pages
[ ] Insurance Company
[ ] Drive By
INSURANCE INFORMATION
VISION Insurance Co.:________________________________MEDICAL Insurance Co.: _________________________________________
Insured Member Name: ________________________________ Patient Relation to Insured:____________________________
Insured Member Social Security #: ______-_____-_______ Insured Date of Birth: _____ / _____ / ______
PLEASE SIGN THE FOLLOWING STATEMENT WHICH ALLOWS DR. BALLARD TO FILE WITH YOUR INSURANCE COMPANY:
I, the undersigned, certify that I (or my dependant) have insurance coverage with the company previously listed, and assign all insurance benefits directly to Ballard Vision
Associates. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the doctor to release all information necessary to
secure the payment of benefits. I authorize the use of this signature for all insurance submissions.
SIGNED: _________________________________________________ DATE: _____ / _____ / ______
HIPPA ACKNOWLEDGEMENT:
My signature below indicates that I have received, reviewed, and understand my right to privacy under HIPPA guidelines.
SIGNED: _________________________________________________ DATE: _____ / _____ / ______
EYE HEALTH HISTORY
Date of Last Eye Exam: _______________________ Name of Eye Doctor or Location: _______________________________________________________
Please mark any problems below that you are currently experiencing:
o NONE
[ ] Blurred Vision- Distance
[ ] Dry Eyes
[ ] Flashes of Light
[ ] Blurred Vision- Computer
[ ] Itchy Eyes
[ ] Floaters
[ ] Blurred Vision- Reading
[ ] Burning Eyes
[ ] Blindspot in vision
[ ] Glare at Night
[ ] Red Eyes
[ ] Crossed Eyes
[ ] Eye Strain
[ ] Sandy or Gritty Sensation
[ ] Dizzy Spells
[ ] Headaches
[ ] Watery Eyes
[ ] Eye Injury
[ ] Loss of Vision-intermittent
[ ] Light Sensitivity
[ ] Stye(s)
[ ] Loss of Vision-constant
[ ] Mucous Discharge
[ ] Color Vision problems
[ ] Double Vision
[ ] Pain or Soreness
[ ] Twitching Eyelid
Do you wear glasses? [ ] Yes [ ] No [ ] Broken [ ] Lost
How old are they? _________________
Do you wear contact lenses? [ ] Yes [ ] No
If YES, please answer the following questions:
What Brand or Type of contact lenses do you wear?______________________________ How old are your current lenses? _________________________
How often do you replace your lenses?______________________ What is your normal wear schedule? _____hours/day _____days/week
What brand of solution do your lenses soak in at night?_______________________________
Are you having any problems with your contact lenses?[ ]Dry out easily [ ]Uncomfortable [ ]Blurry Far Vision [ ]Blurry Near Vision
*PLEASE TURN THIS FORM OVER AND COMPLETE SIDE 2 *

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