Patient Medical and Family History

Welcome!
Patient Information and Registration

Enter the information of the person seeing the doctor.

Red asterisks * indicates required fields.
Patient Name *

First Name Last Name
Patient Date of Birth *

MM DD Year
Patient Gender *
Gender of Patient
Today's Date

Month Day Year
Age
Has the patient visited our office before? *

Yes No
v04-00

Physician Information

Enter physician information of the person seeing the doctor.
Pediatrician or Primary Physician (Name, Specialty, Address & Phone)
Name, specialty, address & phone
Can we send exam results to patient's Physician?
Other Physician(s) Patient Regularly Receives Care (Name, Specialty, Address & Phone)
Name, specialty, address & phone
Other Physician(s) Patient Regularly Receives Care (Name, Specialty, Address & Phone)
Name, specialty, address & phone
Did your Pediatrician or Primary Physician refer us?
If not, who did or or how did you hear of us?

Parent / Legal Guardian Information

Please enter information for at least one parent or legal guardian
Parent 1 Information
Parent 1 Name

First Name Last Name
Parent 1 Email
example@example.com
Parent 1 Phone

Area Code Phone Number
Parent 1 Address

Street Address

Street Address Line 2

City State

Zip Code
Does Parent 1 Have Legal Custody of Child?
Parent 2 Information
Parent 2 Name

First Name Last Name
Parent 2 Email
example@example.com
Parent 2 Phone

Area Code Phone Number
Is Parent 2 Address Same as Parent 1?
Parent 2 Address

Street Address

Street Address Line 2

City State

Zip Code
Does Parent 2 Have Legal Custody of Child?
Legal Guardian's Information
Legal Guardian Name

First Name Last Name
Legal Guardian Email
example@example.com
Legal Guardian Phone

Area Code Phone Number
Legal Guardian Address

Street Address

Street Address Line 2

City State

Zip Code

Person Accompanying Child on Appointment

Please enter information of the person accompanying the child on their appointment
Primary Person Accompanying *
Name of Person Accompanying *

First Name Last Name
Phone of Accompanying *

Area Code Phone Number
Accompanying Person's Relation to Child (Nanny, Sitter, Friend, Aunt, etc.)
Do We Have Your Consent to Treat the Child *

Person Responsible for Account

Please enter information of the person responsible for payment
Same as:
Billing Account Name *

First Name Last Name
Billing Account Email *
example@example.com
Billing Account Phone *

Area Code Phone Number
Billing Address *

Street Address

Street Address Line 2

City State

Zip Code

Patient Information

Medical and Family History

Please enter information regarding the patient seeing the doctor
Why is the patient here to see the doctor?
Please indicate if patient is here for a routine visit or some particular issue or concern.
History of Eye Problems: Has the patient had any of the following?
Eye Exam?
Glasses?
Eye Patching?
Eye Injury?
Eye Surgery?
Other Eye Problems?
Recent Ocular Symptoms: Has the patient had any of the following?
Frequent Tearing or Discharge?
Crossed or Wandering Eye?
Double Vision?
Abnormal Head or Eye Position?
Abnormal Eye Movements?
Excessive Squinting?
Excessive Eye Rubbing?
Change in School or Work Performance?
Frequent Headaches?
Light Sensitivity?
Tired Eyes When Reading?
Clumsiness or Bumping Into Things?
Can't Make Normal Eye Contact?
Blurred Vision?
Other Symptoms?
Review of Medical Symptoms (Medical History): Does the patient currently have or have a history of any of the following? Give details on "yes" reponses.
Fever or Weight Loss?
Birthmarks, Rash or Skin Lesions ?
Frequent Ear Infections?
Other Ear, Nose & Throat Problems?
Developmental Delays?
Behavioral or Attention Deficits?
Heart Murmurs or Other Heart problems?
Asthma or Respiratory Problems?
Arthritis or Joint Problems?
Kidney or Urinary Disease?
Diabetes?
Digestion or Gastrointestinal Disorders?
Sickle Cell Trait or Disease?
Genetic Syndrome?
Seizures or Neurological Problems?
Concussion?
Allergies: Does the patient have any allergies?
To Medications?
To Substances
Surgery or Medications
Has the Patient Ever Had Surgery?
Is the Patient Taking Any Medications, Including Eye Drops?

Birth History

Please enter information regarding the patient seeing the doctor
Birth Weight:
lb.
oz.
Problems During Pregnancy?
Problems During Delivery or Forceps Delivery?
Delivery by Cesarian Section?
Delivered More Than 2 Weeks Early or Late?
Baby Kept in Hospital Due to Illness?
Delayed Development?

Related Family History

Please enter information regarding the patient seeing the doctor
Have any of the patient's relatives had any of the following? Please indicate the relation to the patient.
Glasses Before 6yrs Old?
Amblyopia ("Lazy Eye")?
Patching Treatment?
Strabismus ("Crossed Eye")?
Eye Muscle Surgery?
Genetic Disease (Runs in Family)?
Cataracts in Childhood?
Glaucoma in Childhood?
Other Serious Eye Disease?
Complications From Anesthesia?
Blindness?
Other Serious Illness?
Are Both Parents Alive & In Good Health?
Other Medical Concerns or Problems Not Listed Earlier?

Important Information

Please read and confirm
Insurance

Our office is not a participating provider with health insurance plans and we do not file health insurance claims but we will do our best to guide you.

The receipt we provide at your visit will have a medical procedure and diagnosis code to be used for your insurance reimbursement submission. If you have out-of-network coverage, you can submit this receipt for reimbursement through the vision and/or medical portion of your insurance.

We're happy to help if you have any questions or require any additional assistance.
Terms and Conditions

I certify the above information is correct to the best of my knowledge. I understand that I am financially responsible for this patient's account. I understand that payment is due at time of service. I also acknowledge that a cancellation fee of $25 will be charged if this office is not notified 24 hours prior to cancellation of an appointment, except in the case of an emergency.
Confirmation

I understand that the information that I have given is correct and complete to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my or my child's medical status.

I authorize staff of Pediatric Optometry and Vision Care to perform the necessary in-office examinations that my child (or myself in an adult patient) may need.
Patient Consent

Our Privacy Policy provides information about how we may use and disclose protected health information about you. The Policy contains a Patient Rights section describing your rights under the law. You have the right to review our Policy before signing this Consent. The terms of our Policy may change. If we change our Policy, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor the agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Our Office provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:
• Protected health information may be disclosed or used for treatment, payment or health care operations
• Our office has a Privacy Policy and that the patient has the opportunity to review this Notice
• Our office reserves the right to change the Privacy Policy
• The patient has the right to restrict the uses of their information but our Office does not have to agree to those restrictions
• The patient may revoke this Consent in writing at any time and all future disclosures will then cease
• Our office may condition treatment upon the execution of this Consent
I Have Read the Above and Agree(orig) *
I Have Read & Agree to the Insurance Policy, Terms, Conditions and Consent Above *

Yes
Signature of Patient, Parent or Guardian (draw in box to sign) *
Today's Date *

Doctor's Use Only
Doctor's Attestation

I have verbally reviewed the medical information above with the parent/guardian and/or patient named herein.
Doctor's Signature (draw in box to sign)
Today's Date *
Doctor's Comments

Submit To Our Office

Please hit submit to complete. You will receive an email confirmation.
Once you're done completing all information, please hit the "Submit to our Office" button below to forward your information to us in preparation for your appointment. You will receive an email confirming your submission.

If you have any questions, please ask, email or call our office at 212.410.1291.

Thank you!
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