Patient-Information Step 1 of 2 50% Please fill in the following information to help us provide you with optimum careToday’s Date MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Age M F SS#Patient Name First Middle Last If Minor, Parent(s) Name First Last SS#Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneOccupation Email Address Emergency Contact:Name First Last Relationship PhoneHow did you hear about our office? Friend/Family member Yellow Pages Internet Site/Social Media Insurance Plan Other Referral name What health concerns or problems do you have regarding your eyes today? (check all that apply) Dryness Pain Redness Itch Lid Droop Watery Glare Blur Strain Irritation Haze Light Sensitivity Other Family History of Eye DiseaseDate of last eye exam MM slash DD slash YYYY By whom? First Last Do you currently wear contact lenses? No Yes Type Have you ever been diagnosed with or treated for the following eye problems? (check all that apply) Cataracts Corneal Abrasion Dry eye Injury Iritis/Uveitis Macular Degeneration Lazy Eye Retinal Detachment Infection Allergies Glaucoma Diabetic Eye Disease Other Eye Disorders List Add RemoveEye Surgeries Current Medications (RX or over the counter) I provided a separate medication listlist all medications including eye drops, vitamins & contraceptives below Add RemoveAllergies to medication (please list) Add RemoveAre you a smoker? Yes No pk/dayDrink Alcohol? Yes No pk/dayHave you ever been diagnosed with or treated for the following? (check all that apply) Allergies Anemia Arthritis Asthma High Cholesterol Developmental Disabilities Heart Disease Fibromyalgia Colitis Depression Diabetes Panic/Anxiety Disorder Thyroid Epilepsy Lupus Weight Loss High Blood Pressure Muscular Dystrophy Multiple Sclerosis Cancer Other (type) Are you currently pregnant or nursing? Yes No Name of family physician/practitioner First Last Date of last visit MM slash DD slash YYYY Family Medical and Eye Health HistoryPlease check all the following medical health conditions that have occurred in your family? Cataracts Corneal Problems Diabetes Macular Degeneration Heart Disease High Blood Pressure Glaucoma Retinal Detachment/Disease Other Unknown Financial Policy / Insurance InformationWe ask that all patients read and sign our financial policy prior to seeing the doctor. 1. Payments and all co-payments are due at the time of service. Please indicate your preferred method of payment today: Check/Cash MasterCard/Visa American Express Discover Card Care Credit 2. You will be responsible for all charges that are not covered by your insurance due to co-payments or deductibles. 3. There are no refunds for examinations, treatment, services or material purchases. 4. There will be a $30.00 fee for all returned checks. 5. There will be a $30.00 fee for accounts turned over to our collection agency and additional interest fees may also apply to accounts older than 60 days.About Your Vision and Medical InsuranceThere are two types of third party payors that will help pay for your eye care services and products. You may have both and our practice accepts both. The choice of which to bill is driven by your medical and eye history and/or your symptoms or issues brought up during the exam. Please initial your understanding1. Vision care plans (such as VSP, Davis, Spectera, Avesis, etc.)Vision care plans only cover routine vision exams along with eyeglasses and contact lenses.They do not cover diagnosis, monitoring, management or treatment of eye diseases or visits resulting in prescription medications. 2. Medical insurance (such as Blue Cross Blue Shield, Presbyterian, United Health Care and Medicare)Medical insurance must be used if you have any eye health problems or systemic health issues that are associated with ocular complications (such as diabetes, use of high risk medications and prior eye surgeries).If you have both types of insurance plans it may be necessary for us to bill some services to one plan and some services to the other or separate the services on different days. VSP does allow coordination of benefits to minimize your out-of-pocket expense.We will bill you for any unpaid deductibles, co-payments or non-covered services as allowed by the insurance contract Assignment and Release: I hereby authorize third party or insurance payments to be made directly to Accent on Vision and fully understand that I am the responsible party for all fees incurred by me at the above mentioned facility. I also authorize the release of any information required for the processing of those claims. I, the undersigned, have read and agree to the above policies.SignaturePatient (Parent or Guardian if minor) Date MM slash DD slash YYYY Medical Insurance: Vision Insurance: Name of Insured: Date of Birth of Insured: MM slash DD slash YYYY