Patient History Form

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Personal Information

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Today's Date

Name(Required)

First Last

Preferred Name

Do you have a social security number?(Required)

Yes

No

Social Security #(Required)

Do you have another form of identification?(Required)

Yes

No

If "Yes", please explain(Required)

Have you ever visited our office under another name?(Required)

(divorce, marriage, adoption, etc.)

Yes

No

Marital Status(Required)

Married

Single

Widowed

Divorced

If "Yes", what name?(Required)

Phone(Required)

Email(Required)

Secondary Phone

Sex(Required)

Male

Female

Non Binary

Other

Birth Date(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please type your legal name below as your signature(Required)

Employment Information

Employment Status(Required)

Full Time

Part Time

Other

Employer(Required)

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer Phone

Please type your legal name below as your signature(Required)

Insurance Information

Do you currently have insurance?(Required)

Yes

No

Primary Insurance Provider(Required)

Secondary Insurance

Is the subscriber different than you?(Required)

Yes

No

Subscriber Name(Required)

Relationship to Patient(Required)

Subscribers Birth Date(Required)

Subscribers Social Security #(Required)

Are you currently a resident in skilled nursing home?(Required)

Yes

No

Name of nursing home

Please type your legal name below as your signature(Required)

Referral

Were you referred to Vision Surgery?(Required)

Yes

No

Who were you referred by?(Required)

Consent

Please read the following information

AUTHORIZATION OF TREATMENT: I authorize my physicians Dr. Kingrey, Dr. Boomer, Dr. Fowler, and/or Dr. Brandon Kingrey to examine, diagnose and treat any eye related illness I may have.

AUTHORIZATION TO RELEASE INFORMATION: I authorize Dr. Kingrey, Dr. Boomer, Dr. Fowler, and/or Dr. Brandon Kingrey 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. Fowler, and/or Dr. Brandon Kingrey 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(Required)

yes

Please sign in the box below(Required)

Please type your legal name below as your signature(Required)

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Date of signature

Medical/Pharmaceutical Information

Patient Name(Required)

First Last

Height(Required)

Weight(Required)

Preferred Pharmacy(Required)

Pharmacy Phone(Required)

Pharmacy Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Care Doctor's Name(Required)

First Last

Date last seen(Required)

Primary Care Address(Required)

Street Address Address Line 2 City State ZIP Code

Do you have durable power of attorney?(Required)

Yes

No

If yes, please provide a copy of the durable power of attorney document.

Accepted file types: doc, docx, pdf, jpg, jpeg, gif, png, Max. file size: 10 MB.

Do you have advanced directive (living will)?(Required)

Yes

No

If yes, please provide a copy of the advanced directive (living will).

Accepted file types: doc, docx, pdf, jpg, jpeg, gif, png, Max. file size: 10 MB.

Please type your legal name below as your signature(Required)

Social History

Tobacco use and/or smoking?(Required)

Yes

No

How much tobacco use and/or smoking?(Required)

Have you quit tobacco use and/or smoking?(Required)

Yes

No

How long ago did you quit tobacco use and/or smoking?(Required)

Alcohol use?(Required)

Yes

No

Amount of alcohol use per day or week?(Required)

Illegal drug use?(Required)

Yes

No

Please type your legal name below as your signature(Required)

Surgical History

Have you had previous eye surgery? If yes, what and when?

Have you had any other surgeries?(Required)

Yes

No

Please list any other surgeries:(Required)

Please type your legal name below as your signature(Required)

Medication History

Are you allergic to any medications?(Required)

Yes

No

Please list allergies below(Required)

Medication

Reaction

Are you allergic to latex?(Required)

Yes

No

Describe your reaction to latex:(Required)

Are you currently taking any medications? (prescriptions, over the counter, or eye drops)(Required)

Yes

No

Please list all medications(Required)

Medication

Dosage

How often?

How taken? (oral, drops, injections, etc.)

Please type your legal name below as your signature(Required)

Personal Information

Employment Information

Insurance Information

Referral

Consent

Medical/Pharmaceutical Information

Eye Health History

History of Disease

Social History

Family History

Surgical History

Medication History