Pre-Appointment Screening and History Form
I am a
*
New Patient
Returning Patient
Patient Name
*
First Name
Last Name
Patient Birth Date
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
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Year
Home Address
Street Address
Street Address Line 2
City
State
Zip Code
Email
*
example@example.com
Upload a picture of a government issued photo ID
*
Person filling this form:
Self
Other
Enter your name and relationship to patient
*
Emergency Contact Name
First Name
Last Name
Relationship to Patient
Contact Phone Number
-
Area Code
Phone Number
Do you wear contact lenses?
*
Yes
No
Please upload your most recent prescription or picture of your contacts with lens parameters
*
Upload Files or Picture
Cancel
of
Do you have a primary care doctor?
*
Yes
No
Name of Doctor & Clinic Name
Do you have any allergies (medication and/or environmental)?
*
Yes
No
Please list allergies (medication and environmental) & symptoms:
*
Do you have any new allergies (medication and/or environmental) since your last visit?
*
Yes
No
Please list new allergies (medication and environmental) & symptoms:
*
Do you take any prescription and/or over-the-counter medications?
*
Yes
No
Please list medications with dosages:
Has there been any changes to your current medication since your last visit?
*
Yes
No
Please update your new medications or changes in medication with dosages:
OR
Upload a copy of your medications
Cancel
of
Insurance Information
Please provide a copy of the
front and back
of your
medical
insurance card
Upload your MEDICAL insurance card (.pdf, .jpg, .tiff):
Browse Files
include FRONT & BACK of card
Cancel
of
Please check each box to agree to each condition
*
This office will act as my agent in obtaining payment from my insurance company. However, I understand that I am ultimately responsible for my bill.
In the course of providing treatment to me, this office creates, stores, and receives information that identifies me. The office can use and disclose this identifying information as necessary for my treatment, payment, and healthcare operations.
Payment from any insurance company can be made directly to this office.
A copy of this authorization can be used in place of the original.
This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. Please check if you would like a copy of our HIPAA policy emailed to you:
*
Yes
No
Signature
*
Submit
Date
*
-
Month
-
Day
Year
Date
Should be Empty: