New Patient Form Home » New Patient Form 1Patient Information2Insurance Information3Office Policies and Notice of Privacy Practices4Patient History5Dry Eye Center Today's Date* MM slash DD slash YYYY How did you hear about our office? Is there someone we may thank? First Name* Last Name* Name Prefix? Mr. Mrs. Ms. Miss Rev Dr. Sex Male Female Patient's Social Security #* Date of Birth* Month Day Year Status* Single Married Dating Widow Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*May we notify by text messaging?* Yes No Email* Are you currently employed?* Yes No HiddenEmployer InformationEmployer Occupation PhoneHiddenused for conditionalWill someone else be responsible for bill payment?* Yes No HiddenPerson responsible for bill paymentGuarantor - (Person responsible for bill if other than patient) Guarantor's PhoneRelationship to Patient Guarantor's Employer Guarantor's Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country In Case of emergency Contact or Secondary contact (person not living with patient)First Name* Last Name* Relationship Emergency Contact Phone*Primary Care Physician Primary Care Physician Phone Medical Insurance Information(If you need Prior Authorization from your family physician, please obtain it prior to your visit)Do you have medical insurance? Yes No Hiddenused for conditionalPrimary Medical Insurance Carrier Medical Insurance Policy Number Medical Insurance Group Number Primary Policy Holder Information Same as patient? Primary Policy Holder's First Name Primary Policy Holder's Last Name Primary Policy Holder's SSN Primary Policy Holder's DOB Month Day Year Policy Holder's Employer or Retiree's former employer Hiddenused for conditionalDo you have a secondary medical insurance? Yes No HiddenSecondary Medical Insuranceused for conditionalSecondary Medical Insurance Carrier Policy Number Group Number Primary Policy Holder's Name Social Security Number Date of Birth Month Day Year Policy Holder's Employer or Retiree's former employer Hiddenused for conditionalDo you have vision insurance? Yes No HiddenVision Insuranceused for conditionalVision Insurance Provider Vision Insurance Policy Number Vision Insurance Group Number Primary Policy Holder Information Same as patient? Primary Policy Holder's First Name Primary Policy Holder's Last Name Social Security Number Date of Birth Month Day Year Policy Holder's Employer or Retiree's former employer VISION AND MEDICAL INSURANCE POLICY When your insurance provider(s) has settled your plan’s covered items, you will be notified by a monthly statement if there were any unpaid balances. Unpaid balances can include non-covered items or services, co-pays, deductibles, lapses, ineligibility or termination of coverage. Unpaid balances are the sole responsibility of the patient. The legal obligations of your insurance provider are between yourself and your provider, not between this practice and your provider. Any patient portion amounts on your order will be due at the time of service. I authorize the use of this form on all insurance submissions as well as authorizing the release of information to all my insurance companies as well as allowing the doctor to act as my agent to help me in obtaining payment from my insurance companies. I authorize payment to be made directly to the provider and permit a copy of this authorization to be used in place of the original. REFUND/RETURN POLICY No refund can be made on clinical procedures or services, including comprehensive eye examination, refraction, contact lens fitting, and medical office visits. Refunds or exchanges for frames and frame accessories can only be made within thirty (30) days of receiving the product, provided the product is returned to the store without damage at the time that the refund is issued. Eyeglass lenses are a custom-made item, therefore they are non-refundable and once ordered cannot be canceled. Unopened boxes of contact lenses may be exchanged within thirty (30) days of purchase. Opened boxes of contact lenses are non-refundable or exchangeable. Any orders not picked up within ninety (90) days are returned and deposits are forfeited, unless other arrangements have been made. CONSENT FOR TREATMENT I hereby authorize Alan A. Arabi, O.D., Inc. to administer diagnostic and medical procedures as may be necessary for proper health care. Agree to Terms* I have read and understood the Vision and Medical Insurance Policy, Refund/Return Policy, and accept the Consent for Treatment.Signature of patient or authorized representative*Today's Date* MM slash DD slash YYYY Authorized representative’s name* Relationship* Please read the NOTICE OF PRIVACY PRACTICES FORM that is attached here.Agree to Terms* I have received a copy of the Notice of Privacy PracticesSignature of parent or authorized represenative*Today's Date* MM slash DD slash YYYY Authorized representative’s name* Relationship* Patient HistoryReview of SystemsCheck all that Apply Constitution (Cancer, Developmental Disabilities, Fatigue) Ear/Nose/Throat (hearing loss, sinus) Neurologic (MS, epilepsy, stroke, autism) Psychiatric (depression, anxiety, ADHD) Cardiovascular (high blood pressure, heart disease) Respiratory (asthma, emphysema, sleep apnea) Gastrointestinal (heartburn, crohn's, ulcers) Genitourinary (kidney disease, prostate, STD, pregnant) Musculoskeletal (arthritis, fibromyalgia, gout) Skin (eczema, rosacea, psoriasis) Endocrine (diabetes, thyroid, hormonal dysfunction) Blood/Lymphatic (anemia, blood disorder) Immune Disorder (allergies, rheumatoid, lupus, sjogren's) None of the above Please provide more details about your Constitution symptomsPlease provide more details about your Ear/Nose/Throat symptomsPlease provide more details about your Neurologic symptomsPlease provide more details about your Psychiatric symptomsPlease provide more details about your Cardiovascular symptomsPlease provide more details about your Respiratory symptomsPlease provide more details about your Gastrointestinal symptomsPlease provide more details about your Genitourinary symptomsPlease provide more details about your Musculoskeletal symptomsPlease provide more details about your Skin symptomsPlease provide more details about your Endocrine symptomsPlease provide more details about your Blood/Lymphatic symptomsImmune Disorder (allergies, rheumatoid, lupus, sjogren's)Do you use any EYE medications?* Yes No List any Eye MedicationsDo you use any other medications?* Yes No List all Other MedicationsDo you have any medication allergies?* Yes No List any Allergy MedicationsOther Allergies* Hayfever Ragweed Dust Latex Pets Bees Nuts Shellfish None Eye Surgeries, Injuries, or Trauma Yes No Please list any Eye Surgeries, Injuries, or TraumaHave you ever been diagnosed with: Glaucoma Cataracts Keratoconus Macular Degeneration Amblyopia Retinal Tear/Detachment Strabismus (Lazy Eye) None of the above Other Please describe Do you smoke?* Yes No How much? Do you consume alcohol?* Yes No How much? Immediate Family HistoryCheck all that apply Diabetes Cancer Glaucoma Macular Degeneration High Blood Pressure Other Systemic Retinal Detachment Other Ocular None of the above Dry Eye CenterDry Eye Disease is a common reason for patients to visit eye doctors. Please take a moment to thoughtfully complete this questionnaire. 1. Report the frequency of your symptoms by checking the appropriate box: 0 = never 1 = sometimes 2 = often 3 = constantDryness, Grittiness, or Scratchiness* 0 1 2 3 Soreness or Irritation* 0 1 2 3 Soreness or Irritation* 0 1 2 3 Burning or Watering* 0 1 2 3 Eye Fatigue* 0 1 2 3 2. Report the severity of your symptoms using the rating list below: 0 = No Problems 1 = Tolerable - not perfect, but not uncomfortable 2 = Uncomfortable - irritating, but does not interfere with my day 3 = Bothersome - irritating and interferes with my day 4 = Intolerable - unable to perform daily tasksDryness, Grittiness, or Scratchiness* 0 1 2 3 4 Soreness or Irritation* 0 1 2 3 4 Burning or Watering* 0 1 2 3 4 Eye Fatigue* 0 1 2 3 4 3. Please check if you have experienced the above symptoms Today Within Last 3 days Within past 3 months 4. Do you use eye drops for lubrication? Yes No How many? 5. Do you have fluctuating vision that improves when you blink? Never Sometimes Frequently Always 6. Have you been told you have blepharitis? Yes No 7. Have you been treated for a stye? Yes No NameThis field is for validation purposes and should be left unchanged.
