Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC 28470 Patient Demographic Information Account # Last Name: SSN: / / First: Middle: Marital Status: Single Married Separated Nickname: Divorced Widowed Suffix: Sex: D.O.B. / / Language: English Spanish French Other Salutation: Street/PO Box: Race: American Indian/Alaskan Native Asian City: State: Black Native Hawaiian/Pacific Islander Zip: White Other Communication Preference: Cell E-Mail Home Work US Mail Home ( ) - Cell ( ) - Work ( ) - Email Ethnicity: Not Hispanic/Latino Hispanic or Latino Occupation: Employer: Maiden Name: Birth State: Mother's Maiden Name: Account Responsible check if same as patient Last Name: Suffix: Salutation: First: Middle: D.O.B. / / SSN: - - Street: City: State: Patient Relation: Zip: Email Home ( ) - Work ( ) - Ext. Cell ( ) - Emergency Contact Patient Relationship: Last Name: First: Phone# ( ) - Page 1 of 5
Patient Name: Plan Self-pay / Insurance Name of Insurance Company: Subscribers Name: Subscriber ID#: Group #: *** This office visit may be covered by a major medical insurance or vision plan. Coverage varies and may depend upon the diagnosis reached. For this reason, preparation should be made to pay all deductibles, co-payments, and non-covered service fees. If it is believed that Medicare, Medicaid, BCBS, or supplemental plan may cover services, please tell us now. *** Authorization and Assignment Please Read and Sign. I authorize the release of any medical information necessary to my insurance in order to process my claim. I authorize payment of benefits, if applicable, to Dr. J. Mark Saunders, participation physician, for covered goods and services rendered to me. This is a courtesy to our patients and is not required by law. Signature Optical goods cannot be dispensed until paid in full. Orders for optical goods cannot be placed until a 50% non-refundable deposit is made. We regret we can no longer extend credit to anyone for any reason. We DO accept CareCredit. Privacy Information Please read our privacy notice to understand who we may release your protected health information to as allowed by law. 1. May we have your permission to leave messages regarding appointments or requests for your call back on an answering machine? Yes No Cell phone? Yes No 2. To whom may we release protected health information? Myself only Myself and anyone else involved in my healthcare or payment for my healthcare Myself and Only to the following designated persons Name Relationship Name Relationship HIP A Authorization I acknowledge that I have read and/or received a copy of J. Mark Saunders OD PA s Notice of Privacy Practices Patient Name (Please Print) Signature Date Page 2 of 5
Patient Name: Primary Care Physician Phone # Medications Name Dosage Prescribing Physician Allergies Name Reaction Onset Child Onset Adult YES NO Review of Symptoms (circle all that apply) Constitution (appetite changes, fatigue, loss of sensation, etc.) Cardiovascular (high blood pressure/cholesterol, bypass, stent, pacemaker, etc.) Ear, Nose, Throat (dizziness, hearing loss, oral cancer, vertigo, etc.) Respiratory (asthma, COPD, lung cancer, shortness of breath, etc.) Gastrointestinal (Crohn s disease, reflux, hepatitis, etc.) Genitourinary (cervical/ovarian cancer, prostate cancer, kidney transplant, etc.) Musculoskeletal (bone cancer, arthritis, gout, tendonitis, etc.) Integumentary (dermatitis, skin cancer, lupus) Neurological (bell s palsy, epilepsy, migraines, seizures, stroke, etc.) Psychiatric ( ADHD, depression, dementia, PTSD, etc.) Endocrine (diabetes, hypoglycemia, hypo/hyperthyroidism, etc.) Hematologic/Lymphatic (anemia, leukemia, sickle cell disease, Vit B deficiency, etc.) Allergic/Immunology (autoimmune disorder, bone marrow disorder, HIV/AIDS, etc.) Other Endocrinology Name of Endocrinologist: Phone #: ( ) - Diabetes (circle one) Type 1 Type 2 Last A1C Thyroid (circle one) Hyperthyroidism Hypothyroidism Page 3 of 5
Patient Name: Date of Last Eye Exam Do you wear glasses? If YES, (circle one) Distance Near Full time Do you wear contacts? If NO, are you interested? Brand of Contacts Power Right Eye Power Left Eye Past/Present Ocular History YES NO Glaucoma Cataracts Macular Degeneration Eye Injury Retinal Disease Blindness Strabismus Amblyopic Diabetes Dry Eye Other Previous Eye Surgeries Family History YES NO Whom in family (mother, father, brother, sister, MGM, MGF, PGM, PGF, aunt, uncle, etc.) Glaucoma Cataracts Macular Degeneration Retinal Disease Blindness Strabismus Amblyopic Diabetes Cancer Heart Disease Hypertension High Cholesterol Kidney Disease Stroke Other Social History YES NO FORMER USE Tobacco Drugs Alcohol Amount Used/How Often Date Started/Stopped Page 4 of 5
Patient Dilation Consent Form Dilation is an important part of a complete eye exam. Dilation will make your pupil (the black part in the center of your eye) larger so that Dr. Saunders can get a better look at the back of the eye to check for any problems that can occur due to the following: Systemic Diseases: such as Diabetes, High Blood Pressure, Cancer, etc. that can affect the eyes without obvious symptoms to the patient. Physical Changes in your eyes: such as Cataracts, Glaucoma, Retinal Detachment, etc. that can affect your vision. The dilation will make reading things up close difficult and make lights seem brighter than usual. This will last for 2-3 hours, although it can last longer in some people. Most people will be able to drive once they are dilated as long as they have sunglasses (which we can provide if you didn t bring any). However, if you feel uncomfortable driving or have never driven with your eyes dilated, it may be best to have a driver. It is highly recommended to have your eyes dilated if: You are new to our office You are diabetic You are over age 45 You have a glasses or contact lens prescription over -4.00 Have been previously diagnosed with a condition in the back of the eye that needs yearly monitoring If you do not fit in the above categories, it is still recommended to have your eyes dilated at least every two years. Please check one of the following: I would like my eyes dilated today if the doctor believes it is necessary I would like to schedule a time to come back for the dilation (no additional charge) I do not want my eyes dilated (see below) In refusing to have my eyes dilated, I understand that I am assuming all risks associated with failure to diagnose eye conditions due to the lack of information, which may have been provided by this test. Patient Signature: Date: Print Name: Page 5 of 5