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1530 N Lindberg Cir
Wichita, Kansas 67206
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1100 N Topeka
Wichita, Kansas 67214
Newton
218 S Kansas Ave
Newton, Kansas 67114
Waterfront Surgery Center
1540 N Lindberg Cir
Wichita, Kansas 67206
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Insurance Information
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Subscribers Social Security #
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Are you currently a resident in skilled nursing home?
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Name of nursing home
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Were you referred to Vision Surgery?
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Who were you referred by?
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Please read the following information
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AUTHORIZATION OF TREATMENT: I authorize my physicians Dr. Kingrey, Dr. Boomer, Dr. John, and/or Dr. Klenda to examine, diagnose and treat any eye related illness I may have.
AUTHORIZATION TO RELEASE INFORMATION: I authorize Dr. Kingrey, Dr. Boomer, Dr. John, and/or Dr. Klenda to disclose information regarding my illness to my Physician, Optometrist, Medical Facility, or my Insurance Company. A photostat copy of this authorization will be considered valid.
CONTACT RELEASE INFORMATION: I authorize/permit Vision Surgery Consultants ie: Dr. Kingrey, Dr. Boomer, Dr. John, and/or Dr. Klenda and their business associates to contact me, and all other responsible parties on my account, on our cell phone or other mobile devices concerning any and all aspects of my account.
ASSIGNMENT OF BENEFITS: I assign and authorize for direct payment of medical benefits otherwise payable to me by my insurance to: Vision Surgery Consultants, P.A. I understand that I am financially responsible for charges not covered by my insurance. If incorrect or wrong insurance is supplied to this office, or if I have AN HMO INSURANCE AND DO NOT HAVE PRIOR APPROVAL IN WRITING BY MY PRIMARY CARE PHYSICIAN TO BE SEEN, then I agree to pay for all charges if examined.
CANCELLATION POLICY: If you do not cancel or reschedule your appointment within 24 hours notice, we may assess a $75.00 No-Show service charge. This charge is not reimbursable by your insurance company. You will be billed directly. After three no-shows to your appointment, our practice may decide to terminate its relationship with you.
I have read and agree to the information stated above
Please sign your legal name on the line below
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Medical/Pharmaceutical Information
Patient Name
*
First
Last
Height
*
Weight
*
Age
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Sex
*
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Non Binary
Other
Preferred Pharmacy
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Pharmacy Phone
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Pharmacy Address
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ZIP Code
Primary Care Doctor's Name
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First
Last
Date last seen
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Primary Care Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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Montana
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Do you have durable power of attorney
*
Yes
No
If yes, please provide a copy
Max. file size: 256 MB.
Do you have advanced directive (living will)?
*
Yes
No
If yes, please provide a copy
Max. file size: 256 MB.
Eye Health History
Optometrist's Name
*
First
Last
Date of last eye exam
*
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2012
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2010
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Optometrist's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Do you wear glasses?
*
Yes
No
When do you wear your glasses?
*
All the time
Reading
Driving
Other
What is the age of your current pair of glasses?
*
Do you wear contacts
*
Yes
No
What kind of contacts are you wearing?
*
Hard
Soft
Astigmatism
How many hours/days are you wearing a pair?
*
History of Disease
Are you being treated for or have you had any of the following?
LUNG
Emphysema / COPD/ Asthma
*
Yes
No
Chronic or A.M. Cough
*
Yes
No
Recent “Cold”
*
Yes
No
Shortness of Breath
*
Yes
No
Sleep apnea / CPAP
*
Yes
No
Blood clots / Pulmonary Embolism
*
Yes
No
Wearing Oxygen
*
Yes
No
How much oxygen?
*
VASCULAR
High Blood Pressure
*
Yes
No
Heart Disease/Heart Attack
*
Yes
No
Chest Pain/Angina
*
Yes
No
Coronary Stent
*
Yes
No
Congestive Heart Failure
*
Yes
No
Palpitations/Irreg/A-Fib
*
Yes
No
Pacemaker / AICD
*
Yes
No
Stroke / TIA
*
Yes
No
Bleeding Disorder / Sickle Cell
*
Yes
No
High Cholesterol
*
Yes
No
Year
*
Last Experienced
*
When
*
SYSTEMIC
Diabetes
*
Yes
No
Thyroid Condition
*
Yes
No
Jaundice
*
Yes
No
Kidney / Bladder
*
Yes
No
Dialysis
*
Yes
No
Reflux / Bowel Disease
*
Yes
No
Hepatitis B, C
*
Yes
No
HIV Positive
*
Yes
No
Fainting / Dizziness
*
Yes
No
Tremors / Parkinson’s
*
Yes
No
Seizures / Epilepsy
*
Yes
No
Neuromuscular Disease
*
Yes
No
Restless Leg Syndrome
*
Yes
No
Cancer
*
Yes
No
Autoimmune Disease
*
Yes
No
Dementia / Alzheimer’s
*
Yes
No
Arthritis
*
Yes
No
Back / Neck Problems
*
Yes
No
Are you pregnant now?
*
Yes
No
Depression / Anxiety
*
Yes
No
Blood thinner
*
Yes
No
Shingles
*
Yes
No
Hard of Hearing/Hearing Aid
*
Yes
No
Physical Limitations
*
Yes
No
Had MRSA?
*
Yes
No
Treatment Type
*
Insulin
NonInsulin
Diet
Type
*
1
2
Please list any type of cancer you've had and when you had it.
*
What type(s) of autoimmune disease do you have?
*
Please indicate when and where you had shingles
*
Please explain
*
When and where did you have MRSA?
*
Please list any other serious medical conditions.
Have you ever taken medication for an enlarged prostate?
*
Yes
No
What was the medication?
*
Social History
Tobacco use / Smoking
*
Yes
No
How much?
*
Have you quit?
*
Yes
No
How long ago?
*
Alcohol use
*
Yes
No
Amount per day or week
*
Illegal drug use?
*
Yes
No
Family History
Has any member of your family had these diseases? Check all that apply.
*
Blindness
Cataract
Glaucoma
Diabetes
Hypertension
Heart Disease
Stroke
Cancer
Thyroid Disease
Arthritis
Other heritable disease
None
If other, please explain.
*
Surgical History
Have you had previous eye surgery?
*
Yes
No
Please list
*
Have you had any other surgeries?
*
Yes
No
Please list
*
Medication History
Are you allergic to any medications?
*
Yes
No
Please list allergies below
*
Medication
Reaction
Add
Remove
Are you allergic to latex?
*
Yes
No
Describe reaction
*
Are you currently taking any medications? (prescriptions, over the counter, or eye drops)
*
Yes
No
Please list all medications
*
Medication
Dosage
How often?
How taken? (oral, drops, injections, etc.)
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About
Procedures
Lasik & PRK Surgery
Cataract Surgery
Glaucoma Treatment
Lens Implants
Corneal Surgery
Eyelid Surgery
Pterygium Removal
Cosmetic Eye Surgery
Macular Degeneration
Patient Information
Patient Forms
Payment Options
Testimonials
Eye Surgery Videos
Contact
GIVE US A CALL:
ALL LOCATIONS
316-263-6273
TOLL FREE
1-800-262-0118
East Location
1530 N Lindberg Cir
Wichita, Kansas 67206
Downtown Clinic
1100 N Topeka
Wichita, Kansas 67214
Newton
218 S Kansas Ave
Newton, Kansas 67114
Waterfront Surgery Center
1540 N Lindberg Cir
Wichita, Kansas 67206
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