Date

Name

First Last

Birth Date

Social Security #

Email

(Email is used for appointment reminders, order updates, and occasional newsletters)

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell

Work

Marital Status

Occupation:

Employer:

Languages spoken:

Ethnicity:

How did you hear about our office?

Primary Doctor Name, phone and Fax:

Pharmacy and Location and phone number:

List all medications you take, dosages and frequency (including over-the-counter and home remedies):

Allergy to Medication, food, or other?

Yes
No

if yes please list:

List all major injuries, surgeries and hospitalizations (including eyes):

Are you pregnant or nursing?

Yes
No

Do you use or have you ever used tobacco products?

Yes
No

If yes, type, amount, how long, or when you quit?

Do you drink alcohol?

Yes
No

If yes, type, amount, and how often?

Do you use any other recreational drug?

Yes
No

If yes, type, amount, and how often?

Do you wear glasses?

Yes
No

If yes, how old is your current pair?

Do you wear contact lenses?

Yes
No

If yes, how old is your current pair?

Type of contact lenses:

Brand:

Power: (right):

(left):

EYE CONDITIONS I PROBLEMS

Please list any eye conditions from this list, or any other, on the lines below, and list who has the condition: (for example, Blurred Vision, Light Sensitivity, Double Vision, Dryness, Tearing, Redness, Sandy/Gritty Feeling, Itching, Glare/Halo, Eye Pain, Flashing lights, Floaters, Blindness, Cataracts, Crossed Eyes, Glaucoma, Loss of Vision, Keratoconus, Recurring Eye Infections, Macular Degeneration, Retinal Disease)

Eye Problem (list):

ME
FAMILY MEMBER

Relation to me

ME
FAMILY MEMBER

ME
FAMILY MEMBER

ME
FAMILY MEMBER

MEDICAL CONDITIONS

Please list any eye conditions from this list, or any other, on the lines below, and list who has the condition: (for example, Diabetes, Allergies, Asthma, Anxiety/Depression, Claustrophobia, Auto Immune Disease, Arthritis, Skin conditions, Anemia, Bleeding Issues, Headaches/Migraines, Seizures, Kidney Disease, Cancer (Type), Heart Disease, High Blood Pressure, High Cholesterol, Thyroid Disease, Sleep Apnea, HIV/AIDS, Hepatitis, etc)

Eye Problem (list):

ME
FAMILY MEMBER

Relation to me

ME
FAMILY MEMBER

ME
FAMILY MEMBER

ME
FAMILY MEMBER

Please list hobbies:

Do you use electronics for extended periods of time?

Yes
No

If yes explain

Financial Statement:

I will be responsible financially for any bill incurred on this patient for treatment including reasonable attorney's fees, collections fees, and court costs from all proceedings should I not pay this account in a timely manner. INVe hereby authorize Dr. Hendrickson, or any agency employed by him, to both receive and dispense information regarding my/our credit reference and account. Finance charge is computed by a periodic rate of 1.85% monthly billing cycle, which is an annual percentage rate of 22%, applied to the previous balance after deducting all payments and credits during the billing cycle. To avoid finance charges, pay this account within 30 days of the billing/ insurance transfer date. I understand that I am responsible for the entire amount of the professional fee, for any professional service provided by the doctor or staff, and that I am responsible for the insured and uninsured portion of the bill.

Notice of Privacy Practices Acknowledgement of Receipt:

I acknowledge that I was provided a copy of/read/and understood Clarity Eye Care's Notice of Privacy Practices. By Signing Below, I acknowledge I have read this form in its entirety, filled this form out completely and accurately, and I have been provided the opportunity to ask any questions I may have.

Signature

Date

(If patient is under age 18)

Guarantor's Name:

First Last

Date

Relationship to Patient

Social Security#:

Home Phone

Cell

Address (if different from patient):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email (if different from patient):

Guarantor's Signature:

Date

Witness:

Date

Digital Retinal Photography

Just as many other health professionals use MRI's, mammograms or X-rays to aid in diagnosing health conditions, our office provides a comparable level of quality care with the state-of-the-art iWellness® exam combined with digital retinal photos. The exam is quick, easy and comfortable and allows a detailed view of the inner lining of the eye often without the need of dilation.
Dr. Hendrickson recommends these detailed scans for every patient, as it allows for a powerful way to track subtle changes inside the eye that can otherwise go undetected.
Additionally, we strongly recommend the screening for patients with a personal or family history of high blood pressure, diabetes, macular degeneration, glaucoma, retinal holes, or detachments. The benefits:

An enhanced, high-resolution digital cross-sectional scan and image of the blood vessels and the inner lining of the eye.
The image becomes part of your permanent medical record allowing us to monitor for future changes.
Facilitates the early diagnosis of many health conditions including high blood pressure, high cholesterol, diabetes, macular degeneration and glaucoma.

Generally, insurance does not cover preventative care or the $39 fee of the iWellness® scan and routine retinal photos; as a result, you will be responsible.

I agree to have the Wellness+ digital retinal photography and understand the $39 fee.

I refuse to have digital retinal photography but understand its diagnostic importance

Signature

Date

Patient Information -new