Patient Forms | Riverside Eye Center

Today's Date

First Name*

Last Name*

Date of Birth*

Patient Address*

Your Email Address

Cell Phone Number*

Home Phone Number

Social Security Number*

Gender at Birth*

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Race

White

African American

Hispanic or Latino

Asian

Pacific Islander

Native American

Other

If "Other" was selected, please explain your race below

Primary Insurance Information - Name of Insurance Company

Subscriber's Name

Subscriber's ID

Subscriber's Date of Birth

Subscriber's Employer

Secondary Insurance Information - Name of Insurance Company

Subscriber's Name

Subscriber's ID

Subscriber's Date of Birth

Subscriber's Employer

Referring Doctor - Physician Name

Referring Physician's Address

Referring Physician's Phone Number

Referring Physician's Fax Number

Primary Care Doctor - Physician's Name

Physician's Address

Physician's Phone Number

Physician's Fax Number

Pharmacy Name*

Pharmacy Address

Pharmacy Phone Number

Are you or have you ever been diabetic or prediabetic?*

Yes

No

If "Yes" was selected, do you see a doctor other than your Primary Care doctor for your diabetes?

Yes

No

If "Yes" was selected, please provide the name, address, phone number, and fax number of that doctor below

How did you hear about our office?

Referring doctor

Family or friend

Insurance company

Internet search

Other

If "Other" was selected, please describe how you heard about us here

Patient Employment - Company Name

Company Phone Number

Emergency Contact - First and Last Name

Emergency Contact's Phone Number

Personal Eye History - Please note if you have any of the following conditions:*

Dry Eye

Glaucoma

Macular Degeneration

Cataracts

Lazy Eye

Eye Injury

None

Other eye condition not listed above

List any eye surgeries you have had or write "none"*

List all eye medications you are currently taking (prescription and over-the-counter)*

Personal Medical History - Please note if you have any of the following conditions:*

Diabetes or Prediabetes

Cancer

Heart Disease

High Blood Pressure

Thyroid Disease

High Cholesterol

Arthritis

None

Other medical condition not listed above

List major surgeries you have had or write "none"*

Pneumococcal vaccine received?*

Yes

No

List all medications you are currently taking (prescription and over-the-counter)*

Do you have any allergies to medications/latex/dyes?*

Yes

No

If yes, please list what you are allergic to and describe reaction

Family Medical and Eye History - Please note if any family members have the following conditions:*

Diabetes

Cancer

Heart Disease

High Blood Pressure

High Cholesterol

Arthritis

Glaucoma

Cataracts

Macular Degeneration

Retinal Disease

Lazy Eye

Other

None

If "Other" was selected, please explain condition below

Personal Social History - Do you use or have you ever used tobacco products? *

Yes, currently

Yes, previously

No

If yes, amount/how long?

Do you drink alcohol?*

Yes

No

If yes, how often?

Have you fallen in the past 12 months?*

Yes

No

Please note if you have ever been infected with any of the following:*

HIV

TB

Hepatitis

None

Review of Systems - Please indicate below if you currently have or have had in the last month, any of the following health signs and symptoms:

Eyes*

None

Blurred vision

Loss of vision

Redness

Itching

Burning

Dryness

Excessive tears

Tired/sore eyes

Eye injury

Eye pain

Flashes/floaters

Vision disturbance

Light sensitivity/glare

Eye turn

Double vision

Other

If "Other" was selected, please explain condition below

Constitution*

None

Fever

Weight loss

Chills

Other

If "Other" was selected, please explain condition below

Cardiovascular*

None

Chest pain

Palpitations

Lightheaded

Other

If "Other" was selected, please explain condition below

Ear, Nose, Mouth, and Throat*

None

Hearing loss

Sinus congestion

Sore throat

Other

If "Other" was selected, please explain condition below

Respiratory*

None

Shortness of breath

Pain when breathing

Chronic cough

Other

If "Other" was selected, please explain condition below

Gastrointestinal*

None

Nausea

Constipation

Diarrhea

Other

If "Other" was selected, please explain condition below

Genitourinary*

None

Increased frequency

Increased urgency

Burning/itching

Other

If "Other" was selected, please explain condition below

Muscles/Bones/Joints*

None

Joint pain

Joint swelling

Restricted motion

Other

If "Other" was selected, please explain condition below

Skin*

None

Rashes

Rosacea

Sores

Other

If "Other" was selected, please explain condition below

Neurological*

None

Headaches

Seizures or convulsions

Dizziness

Other

If "Other" was selected, please explain condition below

Psychiatric*

None

Anxiety

Depression

Memory loss

Other

If "Other" was selected, please explain condition below

Endocrine*

None

Frequent urination

Elevated blood sugar

Excessive thirst

Other

If "Other" was selected, please explain condition below

Blood/Lymph*

None

Bleeding disorder

Swollen lymph nodes

Low blood count

Other

If "Other" was selected, please explain condition below

Allergic/Immunologic*

None

Seasonal allergies

Suppressed immune system

Allergic rhinitis

Other

If "Other" was selected, please explain condition below

Please explain any of the signs and symptoms that you checked above:

Refraction Agreement - A refraction is the part of the eye exam that determines your eyeglass prescription. Although this test is a very important part of your exam and is required for certain surgical procedures (such as cataracts), it is not considered a "medical procedure". Therefore, most medical insurances, including Medicare, will not cover the cost of the refraction. If you have "vision insurance" such as VSP, Eyemed, etc. it may cover the refraction fee. For more information regarding the refraction and/or to find out if your insurance covers this service, please feel free to call our office. The charge for this service is $49.00. Indicate below if you would like this service.

Do you want a refraction done at your appointment? *

Yes

No

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature*

Today's Date

Privacy Policy Statement - I have the opportunity to object to and revoke the disclosure of my protected health information at any time, but by typing your name below, I agree to give Riverside Eye Center and MD Eye Center and its staff members permission to use and disclose my protected health information to the staff, other practitioners, insurers, public health agencies, and when required by law. I agree to have the staff call me regarding my treatment, insurance and/or billing information, normal test results, and appointment dates. I understand that a message may be left by voice mail, sent by fax, emailed, or left with a designated person of my choosing. By typing my name below, I consent to receive SMS test messages from Riverside Eye Center or MD Eye Center for appointment reminders, marketing messages, and general two-way communication. Message frequency varies. Message and data rates may apply. Consumer information is not shared with third parties for marketing purposes.*

Today's Date

One Time Authorization Agreement - I request that payment of authorized insurance benefits be made to Riverside Eye Center or MD Eye Center for any services furnished to me by this provider. I authorize any holder of medical or other information about me to be released to my insurers and their agents. This includes any information needed to determine these benefits for related services. I permit a copy of the authorization to be used in place of the original. If my insurance fails to pay for a service, even if me or my doctor feel it is beneficial, I understand that I may be responsible for those charges. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.*

Today's Date

HIPAA/Release of Medical Information - May we give your test result and any medical information to another person if you are not available?*

Yes

No

If "Yes" was selected, please list the name and phone number of the person of your choosing below

May we leave results on your voicemail answering machine?*

Yes

No

By typing my name below, I agree to the HIPAA/release of medical information listed above. I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.*

Fort Gratiot Office: (810) 385-3600

East China Office: (810) 329-9045

Macomb Office: (586) 416-1544

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