Name: Bob Ham Eyewear
Address: 9965-24 San Jose Blvd, Jacksonville, FL, 32257, US
Price range: $000 - $300

We have a new appointment system. Please use the link below to go to our new website and schedule your appointment
Click here to schedule your appointment
Or go directly to our new website: www.BobHamEyewearJAX.com
Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Type*
- New Patient
- Returning Patient
Name*
First Middle Last
Gender
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Work Phone*
Birth Date*
MM slash DD slash YYYY
Age
Occupation
Place of Employment/School
Email*
If Married, Spouse's Name
If Child, Parent's Name
If paying by check, driver's license
State
Emergency contact
Name
Phone
HIPPA (Health Information Privacy and Portability Act): I have read and understand the office HIPPA policy (attached to clipboard). Signature below is only acknowledgement that I have seen and read this policy.
Patient (or guardian) signature
Date
MM slash DD slash YYYY
Vision Insurance
I understand that verification of coverage must be done PRIOR to exam/services. Otherwise, patient will be responsible for filing for insurance benefits.
Patient (or guardian) signature
Date
MM slash DD slash YYYY
NOTE: We are providers for Eyemed plans. Please present card & valid ID at front desk.
Eyemed plan name*
Policy #*
Policy #
Patient's Social Security
Patient's DOB
MM slash DD slash YYYY
Responsible member (if different than patient): Name
S. S. #
DOB
MM slash DD slash YYYY
Employer
Medical information release: I request that payment of authorized insurance be made either to me or on my behalf to Dr. Sheila Merritt for any services furnished me by that doctor. I authorize any holder of medical information about me to release to the health care administration and its agents any information needed to determine these benefits or the benefits payable for related services.
Patient (or guardian) signature
Date
MM slash DD slash YYYY
Eye History
Reason for today's visit*
Date of last exam
MM slash DD slash YYYY
Any special eye or vision problems
List any previous eye injuries or surgeries
Does your work require special vision care? Explain
Please list hobbies/activities that may require special vision care
How did you hear about our office?
Contact Lens Info
Do you desire an evaluation for contacts &/or update contact Rx today?*
- Yes
- No
Do you currently wear contact lenses?*
- Yes
- No
Or have you worn thern before?*
- Yes
- No
If Yes. what kind?
- Soft
- Rigid
- Disposables
- Monovision
- Bifocal
- Astigrnatic(torics)
Which brands have you worn?
How many years have you worn contacts?
Do you sleep in your contact lenses?
- Yes
- No
Or do you remove them nightly?
- Yes
- No
What solutions do you use?
Medical History
Below are questions about your ocular and family medical history. Due to your eyes being directly affected by your general health, medical problems, and the medications you take, please answer completely so we can better care for your visual needs.

Eye conditions/symptoms you have (or have had)

	Yes	No
Blurred vision
Cataracts
Double vision
Eye pain
Eyelid problems
Halos
Retinal problems
Lazy eye
Eye color
Glaucoma
Dry eyes
Floater/spots
Redness
Itching
Tearing
Infection
Blindness
Eye injury
Flashes
Light sensitivity
Macular degeneration

Do you have (or have had)?

	Yes	No
Diabetes
High blood pressure
Headache
High cholesterol
Asthma
Arthritis
Stroke
Anemia
Hay fever
Lung disease
Skin disorder
Cancer
Seizure
Sinus problems
Heart disease
Thyroid disease
Kidney disease
Gastrointestinal disorder
Neurological
Auto Immune disease
HIV positive

Are you pregnant or nursing?
- Yes
- No
Are you taking any medications (including over-the-counter meds, vitamins, and herbal supplements)?
- Yes
- No
Please list
Are you allergic to any medications?
- Yes
- No
Please list
Do you have allergies (seasonal, etc.)?
- Yes
- No
Please list
Medical doctor
Medical doctor's phone
Last visit
MM slash DD slash YYYY
Does anyone in your family have any of the following medical problems?
Yes No
Diabetes
High blood pressure
Heart disease
Migraines
High cholesterol
Thyroid problems
Cancer
Glaucoma
Cataracts
Blindness
Color deficiency
Retinitis Pigmentosa
Macular Degeneration
Other
If Other Explain
Dilation
Although we can determine a spectacle prescription without a dilated fundus exam, this only provides a limited view of the inside of your eye and some very serious conditions may go undetected including, but not limited to, retinal holes, tears, and detachments. Drops are placed in the eyes to enlarge the pupils. This dilation usually lasts for 2-6 hours. During this time, your eyes will be sensitive to light and your vision may be blurry, especially at near. This procedure is included in your comprehensive eye exam.
- I can have this procedure today.
- I am unable to do this procedure today and need to reschedule it.

Located

Our Hours

Monday: 9:00 AM - 6:00 PM
Tuesday: 9:00 AM - 6:00 PM
Wednesday: 9:00 AM - 6:00 PM
Thursday: 9:00 AM - 6:00 PM
Friday: 9:00 AM - 6:00 PM
Saturday: 9:00 AM - 12:00 PM
Sunday: Closed

Quick Links

We are Social

Patient Form

We have a new appointment system. Please use the link below to go to our new website and schedule your appointment

Click here to schedule your appointment

Or go directly to our new website: www.BobHamEyewearJAX.com

Emergency contact

Vision Insurance

Eye History

Contact Lens Info

Medical History

Dilation

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Bob Ham Eyewear