Welcome to Washington Eye Doctors!

Name

Prefix First Last

Date of Birth

Age

Preferred Language:

English
Spanish

Race:

Ethnicity:

Hispanic or Latino
Native Hawaiian/Pacific Island
Not Hispanic or Latino

Communication, Preferred:

Email
Postal
Telephone

If Child, Name of Parent/Guardian

School Grade

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Soc. Sec. #

Cell Phone

Fax #

E-mail

Referred by

Employer

Occupation

Employment Status:

Full-time
Part-time
Student
Unemployed

Marital Status:

Married
Single
Widow/Widower
Domestic Partner

General Health Insurance Company Name:

Health Insurance Group Number:

Health Insurance Member ID Number:

Relationship to Insured:

Self
Spouse
Dependent/Child

If insured is spouse, name of spouse:

Vision Insurance Company Name:

Reason for this Examination:

Do you have, or is there any family history of:

	Self	Family
Glaucoma
Headaches
Double Vision
Cataracts
Flashes, Floaters
Eye discomfort/Irritation
Eye Surgery
Eye Head Injury
Blindness
Eye Exercises/ Vision Training
Heart/Vascular Problems
Reading difficulty
Hypertension
Diabetes
Arthritis
Sudden Vision Loss
Allergies
Other

If other, please specify:

Are there any other general health or eye problems that you wish to discuss:

Do you use cigarettes/tobacco?

Yes
No

Alcohol?

Yes
No

Other Substance(s)?

Are you pregnant or nursing?

Yes
No

List any medications, vitamins, shots, etc that you presently take:

Date of last eye examination

Doctor

City

Name of regular physician

City

Do you presently wear glasses?

Yes
No

If Yes, age of present prescription

Do you wear contact lenses?

Yes
No

If Yes, how old are they?

Right Left

Did you ever try contact lenses?

Yes
No

If Yes, why did you stop?

- Professional fees are due when service is rendered.

- Eyewear must be paid for in full when ordered.

- There is a $25.00 fee for all returned checks.

- A collection fee equal to 35% of the balance due will be added to all accounts referred for collection services.

- Patients are responsible for all charges not paid by their insurance carriers.

- The practice reserves the right to charge for cancelled or missed appointments with less than 24 hours notice.

By signing below, I agree to the INSURANCE AUTHORIZATION POLICY, and have read and understood the NOTICE OF PRIVACY PRACTICES and ACKNOWLEDGEMENT.

(Clicking on the following 3 links will open these documents as PDFs for you to read.)
INSURANCE AUTHORIZATION POLICY
NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT

Signature

If you have questions about any of the following, please mark with a check:

Contact Lenses

Glasses

If other, please specify:

So that we may better meet your vision needs, please complete this lifestyles questionnaire. Please check the activities you MOST OFTEN participate in.

M
F

Sports

If other, please specify:

Physical Fitness

If other, please specify:

Social/Hobby

If other, please specify:

Business

If other, please specify:

	Yes	No
Does the glare from headlights or indoor lighting affect your vision or comfort?
Have you ever experienced skin irritation caused by corrosion of your spectacle frame?
Do you normally wear sunglasses?
Are there times you would like to see clearly, but your glasses are inappropriate?
Are you interested in Laser Vision Correction?

Office Hours

Patient Registration Form

So that we may better meet your vision needs, please complete this lifestyles questionnaire. Please check the activities you MOST OFTEN participate in.