Patient Information Dr. Mrs. Ms. Mr. Hey You!
Male Female Other
Do you speak English fluently?
(if not, please your primary language below) Yes No
We do not share with anyone other than
YOUR insurance company *
Who may we thank for referring you?
How did you hear about us? (check all that apply)
Doctor Co-worker Yelp Friend Insurance Your Worst Enemy Newspaper Family Employer Radio Billboard Neighbor Facebook TV Vision Insurance Primary (please input N/A if no insurance or you are paying privately)
Yes No Reading Glasses Only
Do you wear contact lenses?
Does your vision WITH Correction limit any daily living (driving, reading, sports, work, hobbies, etc.)
Yes No Insurance
List any current medications you are taking (Rx and OTC)
Write N/A or none if none *
Are you allergic to any medications? * (If yes, specify below) Yes No
Please list all major illnesses or injuries (Glaucoma, Diabetes, High Blood Pressure, Heart Disease, Concussion, etc.) *
List any surgeries you have had: (Cataract, Laser, Vitreous Injections, Appendectomy) *
Have you ever had a blood transfusion? *
Yes No Are You Experiencing Issues In Any Of The Following Areas? Yes No
General constitution: fever, weight loss or gain, tired, etc
Ears, nose, throat: stuffy nose, ear ache, cough, dry mouth, hard of hearing, etc
Cardiovascular: high blood pressure, high cholesterol, racing pulse, etc
Respiratory: congestion, wheezing, shortness of breath, asthma, etc.
Gastrointestinal: stomach upset, diarrhea, constipation, hernia, ulcers, etc.
Genital, Kidney, Bladder: painful, frequent urination, impotence, jaundice, etc.
Muscles, Bones, Joints: pain, stiffness, swelling, cramps, arthritis, etc.
Skin: acne, warts, growths, rash, etc.
Neurological: numbness, headache, seizures, paralysis, etc.
Psychiatric: anxiety, depression, insomnia, etc.
Endocrine: diabetes, hypothyroid, hyperthyroid, etc.
Blood, Lymph: bleeding, high cholesterol, anemia related to transfusion, etc.
Allergic, Immunologic, sneezing, swelling, itching, hives, Lupus, etc.
Please check all that apply
None Macular Degeneration Stroke Other Intolerable Disease Blindness Diabetes Cancer Rockin' Pneumonia and the Boogie Woogie Flu Cataract Hypertension Thyroid Disease Glaucoma Heart Disease Arthritis Social History
Please check all that apply
No Rarely 1 a day 2-3 a day 4+ a day No Rarely < 10 a day 11-20 day 21+ a day
Is there anything specific you wish to discuss with the doctor?
Lasik Contact Lenses Dry Eye Aesthetic optometry Myopia control Other (describe below)
The following people are allowed to access my records, and/or pick up any products for me
This will need to be signed in-person to activate
I have read and agree to the HIPAA Privacy *
HIPAA Privacy Acknowledgment of Receipt of Privacy Notice By Signing this acknowledgement of Receipt of Notice of Privacy Practices (the “Notice”); I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that Bella Eye Care may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit Bella Eye Care to perform its administrative duties, provide me with eye care services and products, process my vision (and/or medical) benefit claims and communicate with me regarding vision care services provided by Bella Eye Care (for example, mailings of exam reminders or information about services/products provided by Bella Eye Care). I can be assured that Bella Eye Care does not sell my personal health information of any kind to a third party for such party’s own use. I acknowledge and agree that Bella Eye Care may submit my vision and/or medical benefits claims to my plan sponsor or health plan to receive reimbursement direction for the vision services and products I have received from the Bella Eye Care. Patient Agreement: I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account. I understand that if for any reason my insurance company denies payment for services rendered I am responsible for payment in full. I authorize the release of any pertinent information for claims to be processed. I allow this to be used for Signature on File. ALL PROFESSIONAL FEES ARE NON-REFUNDABLE. ALL CONTACT LENS CHECK/FOLLOW UPS AFTER 90 DAYS ARE $50.
I have read and agree to the Payment Agreement *
The patient’s portion must be paid at the time services are rendered. The undersigned will ultimately be responsible for any bill incurred in this office. Insurance verification is not a guarantee of payment by your insurance/vision plan. There will be a service charge on all returned checks. By signing below, I state that I have read and understand the Notice of Privacy Practices for this office. I authorize Bella Eye Care Optometry to release and obtain any medical records for the specified individual to the insurance provider and/or co-managed practitioner if necessary.