Patient Form 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.Name First Middle Last GenderMaleFemaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneCell PhoneWork PhoneBirthDate Date Format: MM slash DD slash YYYY AgeOccupationPlace of Employment/SchoolEmail If Married, Spouse's NameIf Child, Parent's NameIf paying by check, driver's licenseStateEmergency contactNamePhoneHIPPA (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) signatureDate Date Format: MM slash DD slash YYYY Vision InsuranceI 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) signatureDate Date Format: MM slash DD slash YYYY NOTE: We are providers for Eyemed plans. Please present card & valid ID at front desk. Eyemed plan namePolicy #Policy #Patient's Social SecurityPatient's DOB Date Format: MM slash DD slash YYYY Responsible member (if different than patient): NameS. S. #DOB Date Format: MM slash DD slash YYYY EmployerMedical 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) signatureDate Date Format: MM slash DD slash YYYY Eye HistoryReason for today's visitDate of last exam Date Format: MM slash DD slash YYYY Any special eye or vision problemsList any previous eye injuries or surgeriesDoes your work require special vision care? ExplainPlease list hobbies/activities that may require special vision careHow did you hear about our office?Contact Lens InfoDo you desire an evaluation for contacts &/or update contact Rx today?YesNoDo you currently wear contact lenses?YesNoOr have you worn thern before?YesNoIf Yes. what kind?SoftRigidDisposablesMonovisionBifocalAstigrnatic(torics)Which brands have you worn?How many years have you worn contacts?Do you sleep in your contact lenses?YesNoOr do you remove them nightly?YesNoWhat solutions do you use?Medical HistoryBelow 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)YesNoBlurred visionCataractsDouble visionEye painEyelid problemsHalosRetinal problemsLazy eyeEye colorGlaucomaDry eyesFloater/spotsRednessItchingTearingInfectionBlindnessEye injuryFlashesLight sensitivityMacular degenerationDo you have (or have had)?YesNoDiabetesHigh blood pressureHeadacheHigh cholesterolAsthmaArthritisStrokeAnemiaHay feverLung diseaseSkin disorderCancerSeizureSinus problemsHeart diseaseThyroid diseaseKidney diseaseGastrointestinal disorderNeurologicalAuto Immune diseaseHIV positiveAre you pregnant or nursing?YesNoAre you taking any medications (including over-the-counter meds, vitamins, and herbal supplements)?YesNoPlease listAre you allergic to any medications?YesNoPlease listDo you have allergies (seasonal, etc.)?YesNoPlease listMedical doctorMedical doctor's phoneLast visit Date Format: MM slash DD slash YYYY Does anyone in your family have any of the following medical problems?YesNoDiabetesHigh blood pressureHeart diseaseMigrainesHigh cholesterolThyroid problemsCancerGlaucomaCataractsBlindnessColor deficiencyRetinitis PigmentosaMacular DegenerationOtherIf Other ExplainDilationAlthough 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 Call have this procedure today.I am unable to do this procedure today and need to reschedule it.
