Image Eye Care
Call Us: (636) 447-2244
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Patient Forms

Patient Registration Form

PATIENT INFORMATION
Last Name
First Name
Middle Initial
Address
State / Zip
Telephone
Date of Birth
Email Address
Last Four Digits Of Social Security Number
Occupation (Grade in School)
Employer (School Name)
Family members seen at our practice:
Race
Preferred Language
Ethnicity
Do you own or have you ever purchased blue light blocking glasses?
MEDICAL HISTORY
PRIMARY CARE PHYSICIAN
PCP PHONE NUMBER
DATE OF LAST PHYSICAL
Do you use tobacco products?
Do you drink alcohol?
Do you use recreational drugs?
Women: Pregnant/Nursing?
Do you currently wear corrective eyewear?
If Yes, please check all that apply:
If using contact lenses, what brand(s) are you using?
How often do you replace your contacts and what type of solution do you use to clean and store your contacts?
Approximately when was your last eye exam?
Doctors Name:
City, State, Phone:
MEDICAL CONCERN (Please Specify)
OTHER VISION CONCERN (Please Specify)
Please indicate medications you're currently taking:
Please indicate if you have any allergies to medicines
DO YOU OR A FAMILY MEMBER HAVE ANY OF THE FOLLOWING CONDITIONS?
Eye Health
DO YOU OR A FAMILY MEMBER HAVE ANY OF THE FOLLOWING CONDITIONS?
Systemic Health
High Blood Pressure
Diabetes
Heart Disease
Migraine/Headache
Neurological Disorder
High Cholesterol
Thyroid Disorder
Cancer
Autoimmune Disorder
Psychiatric Disorder
Number of hours working on a computer
Are you bothered by glare in the office/workplace?
Please list any hobbies, activities, or sports you enjoy
INSURANCE / VISION CARE COVERAGE
Vision Care Coverage:
Name of Insurance Plan:
Vision Plan I.D. Number:
Primary Insured's Name:
Primary Insured's Date of Birth:
Vision Care Insured Last 4 Social Security Numbers:
Relationship to Insured:

Medical Insurance:
Name of Insurance Plan:
Insurance I.D. Number:
Group Number:
Primary Insured's Name:
Primary Insured's Date of Birth:
Relationship to Insured:
Medical Insurance Phone Number for Providers:
Secondary Insurer (if any)
ID Number:
Secondary Medical Insurer


PLEASE BRING INSURANCE CARDS TO APPOINTMENT.

WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE
Name:
Name:
Name:
AUTHORIZATION & NOTICE OF PRIVACY PRACTICES
PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE:

I authorize the release of any medical or other information necessary to process insurance claims. I also request payment of benefits either to myself or to the party who accepts assignment. I understand that I am responsible for any balance due for services and/or products that are deemed "not covered" or denied or delayed (over 60 days) by my benefit plan.

NOTICE OF PRIVACY PRACTICES

By signing/typing your name in the field below, you have read, understand, and acknowledge that you have received a copy of the Image Eye Care Notice of Privacy Practices.

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