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.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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 contactName PhoneHIPPA (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 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 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 SecurityPatient'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) signatureDate MM slash DD slash YYYY Eye HistoryReason 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 InfoDo 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 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? Yes No Are you taking any medications (including over-the-counter meds, vitamins, and herbal supplements)? Yes No Please listAre you allergic to any medications? Yes No Please listDo you have allergies (seasonal, etc.)? Yes No Please listMedical doctor Medical doctor's phoneLast visit 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 Explain DilationAlthough 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.
