PATIENT NAME:*
Date*
Date Format: MM slash DD slash YYYY
PATIENT DATE OF BIRTH:*
OFFICE LOCATION:* Upper West Side Tribeca Brooklyn
PATIENT INFORMATION PATIENT GENDER:
PATIENT AGE:
OCCUPATION:
ADDRESS:
HOME PHONE:
MOBILE PHONE:
OTHER PHONE:
PHARMACY PHONE:
EMAIL ADDRESS:
(patient’s or parent’s email)
GUARANTOR OF PAYMENT NAME:
DATE OF BIRTH:
ADDRESS:
PHONE:
SS#:
INSURANCE PRIMARY INSURANCE COMPANY NAME (primary)
SUBSCRIBER:
DATE OF BIRTH:
PATIENT ID:
POLICY GROUP:
PATIENT’S RELATIONSHIP TO SUBSCRIBER:
PRIMARY INSURANCE CARD (FRONT) PRIMARY INSURANCE CARD (BACK) SECONDARY INSURANCE COMPANY NAME:
SUBSCRIBER:
DATE OF BIRTH:
PATIENT ID:
POLICY GROUP:
PATIENT’S RELATIONSHIP TO SUBSCRIBER:
SECONDARY INSURANCE CARD (FRONT) SECONDARY INSURANCE CARD (BACK) REFERRED BY: NAME:
ADDRESS:
PHONE:
PRIMARY PHYSICIAN: NAME:
ADDRESS:
PHONE:
COVID-19 SCREENING please read carefully
Have you or the patient traveled outside of New York/New Jersey/Connecticut for greater than 24 hours in the past 14 days?* YES NO
Is your or the patient’s temperature greater than 100°, off of fever reducing medications?* YES NO
Do you or the patient have a new onset or worsening of two or more of the COVID-19 symptoms (cough, shortness of breath, fever, chills, muscle pain, headache sore throat, new loss of taste or smell)?* YES NO
Are you or the patient under quarantine recommendations for any reason?* YES NO
Attestation: I understand the hazards of the novel coronavirus (“COVID-19”) and am familiar with the Centers for Disease Control and Prevention (“CDC”) guidelines regarding COVID-19. I acknowledge and understand that that the circumstances regarding COVID-19 are changing from day to day and that, accordingly, the CDC guidelines are regularly modified and updated and I accept full responsibility for familiarizing myself with the most recent updates.
I agree to adhere to Pediatric Ophthalmic Consultants (“The Practice”) guidelines and safety protocols. The Practice shall not be held responsible for any virus transmission regardless of the cause. I therefore release and hold harmless the Practice and its employees from all claims, damages and other liability arising from virus transmission.
Signature* Patient or Patient’s Guarantor
PRINT NAME:*
PATIENT AND GUARANTORS RESPONSIBILITIES please read carefully
*The cost of today’s ophthalmic medical exam is $350 for an established patient or $550 for a new patient (or for an exam occurring more than 5 years since prior exam here), unless a surgical procedure is also performed during the exam. Refraction, sensorimotor examination, ophthalmoscopy, and when needed ocular photos are necessary for a complete ophthalmic medical exam.
Initialing each section indicates your understanding of the following policies. If these responsibilities are not met, then you will be billed for the cost* of today’s visit.
Initial 00* Initial Please:
Please present the patient’s current, primary medical insurance card to our front desk. If a child is covered by two insurance plans, then the plan of the parent whose birthday occurs later in the year is considered secondary. If we do not have knowledge of the primary, active medical plan, then you will be responsible for the cost* of today’s visit.
Initial 01* Initial Please:
Please acquire referrals required by your medical insurance plan. If your plan requires a referral from the primary care physician for specialists office visits, then you will need an active referral for today’s visit. If
you proceed to receive services in the absence of the required referral, then you will be responsible for the cost* of today’s visit.
Initial 02* Initial Please:
Please be aware of your medical deductibles. We do not participate with any “vision benefit” policies. Today’s visit will not be applied to your vision benefits or your routine eye benefits. Today’s costs will be processed through the patient’s medical benefits. If your in-network deductible has not been satisfied, then you will be responsible for part or all of the cost of today’s visit.
Initial 03* Initial Please:
Please be aware of your medical coverage. Our doctors are obligated to perform a REFRACTION upon all new patients and for most follow-up patients regardless of age and diagnosis. REFRACTION refers to the measurement of the focusing characteristics of the eye. Insurance companies now mandate that the REFRACTION procedure be charged separately from the rest of the eye exam. Some insurance companies do not pay specialists for the REFRACTION portion of the eye exam. If your insurance plan is one that NEVER covers this procedure, we will expect $45 in addition to the usual copay at the time of visit. If our submitted REFRACTION claim to your insurance company is uncovered, then you are responsible for the $45 REFRACTION fee.
Initial 04* Initial Please:
Please note that medical specialist copayments will be collected at the time of service. If you are unable to pay
your copayment today, then a $10 administrative fee will be added to your costs.
Initial 05* Initial Please:
Please note our rescheduling policy. If you do not show for a scheduled appointment or cancel within less than
24 hours of the time of your scheduled appointment, then a $25 rescheduling fee will be added to your costs.
Initial 06* Initial Please:
Please acknowledge this guarantor agreement. By presenting my credit card to the receptionist at the front desk,
I understand that it will be saved through a secure payment processing platform supported by Level 1 PCI Compliance. I authorize, without prior notification, eventual payment with said credit card for the amounts the provider is contractually obligated to collect including, but not limited to: copayments, co-insurance, deductibles and/or uncovered services.
Initial 07* Initial Please:
I accept responsibility for and guarantee payment for any fees charged for the patient’s treatment, regardless of any insurance benefits the patient is entitled to, and assign the benefits payable for physician services to the physician.
I have read the notice of Privacy Practices. If I request a copy of today’s consult report, unless I indicate otherwise, this will be sent via email. Also a reminder for any follow up appointments may be sent via email unless I indicate otherwise. I also consent to permitting use of the patient’s photograph for medical education programs and medical publications. I agree that Pediatric Ophthalmic Consultants may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payors for treatment purposes.
SIGNATURE:* Patient or Patient’s Guarantor
PRINT NAME:*
REVIEW OF SYSTEMS ENTER REASON FOR VISIT:*
FAMILY HISTORY IF ANY BLOOD RELATIVE HAS SUFFERED ANY OF THE FOLLOWING – PLEASE CHECK & INDICATE WHICH RELATIVE
DISEASE: RELATIVE (EPILEPSY)
RELATIVE (MIGRAINE)
RELATIVE (MENTAL ILLNESS)
RELATIVE (GLAUCOMA)
RELATIVE (DIABETES)
RELATIVE (THYROID)
RELATIVE (HAY FEVER)
RELATIVE (ASTHMA)
RELATIVE (BLEEDS EASILY)
RELATIVE (OSTEOPOROSIS)
RELATIVE (ARTHRITIS)
RELATIVE (HEART DISEASE)
RELATIVE (STROKE)
RELATIVE (HYPERTENSION)
RELATIVE (HIGH CHOLESTEROL)
OTHER DISEASE 01:
RELATIVE (OTHER DISEASE 01)
OTHER DISEASE 02:
RELATIVE (OTHER DISEASE 02)
OTHER DISEASE 03:
RELATIVE (OTHER DISEASE 03)
OTHER DISEASE 04:
RELATIVE (OTHER DISEASE 04)
OTHER DISEASE 05:
RELATIVE (OTHER DISEASE 05)
HOSPITAL ADMISSIONS (Not including pregnancies)
01. YEAR
01. ILLNESS OR OPERATION
02. YEAR
02. ILLNESS OR OPERATION
03. YEAR
03. ILLNESS OR OPERATION
04. YEAR
04. ILLNESS OR OPERATION
05. YEAR
05. ILLNESS OR OPERATION
06. YEAR
06. ILLNESS OR OPERATION
MEDICATIONS List all medication you are now taking – Include those you buy without a prescription.
MEDICATION 01:
MEDICATION 02:
MEDICATION 03:
MEDICATION 04:
MEDICATION 05:
MEDICATION 06:
MEDICATION 07:
MEDICATION 08:
MEDICATION 09:
MEDICATION 10:
MEDICATION 11:
MEDICATION 12:
ALLERGIES ALLERGY 01:
ALLERGY 02:
ALLERGY 03:
ALLERGY 04:
MEDICAL HISTORY Select the "Symptoms/Diseases" from the list that apply and specify "current condition" or "past condition." If "past condition," please indicate your age when resolved.
DECREASED HEARING N/A CURRENT CONDITION PAST CONDITION
Decreased Hearing (Age Resolved)
Ringing in Ear N/A CURRENT CONDITION PAST CONDITION
Ringing in Ear (Age Resolved)
Ear Infections - Frequent N/A CURRENT CONDITION PAST CONDITION
Ear Infections - Frequent (Age Resolved)
Dizzy Spells N/A CURRENT CONDITION PAST CONDITION
Dizzy Spells (Age Ressolved)
Failing Vision N/A CURRENT CONDITION PAST CONDITION
Failing Vision (Age Resolved)
Fainting Spells N/A CURRENT CONDITION PAST CONDITION
Fainting Spells (Age Resolved)
Eye Pain N/A CURRENT CONDITION PAST CONDITION
Eye Pain (Age Resolved)
Double or Blurred Vision N/A CURRENT CONDITION PAST CONDITION
Double or Blurred Vision (Age Resolved)
Eye Infections - Frequent N/A CURRENT CONDITION PAST CONDITION
Eye Infections - Frequent (Age Resolved)
Nose Bleeds - Recurrent N/A CURRENT CONDITION PAST CONDITION
Nose Bleeds - Recurrent (Age Resolved)
Sinus Trouble N/A CURRENT CONDITION PAST CONDITION
Sinus Trouble (Age Resolved)
Sore Throats - Frequent N/A CURRENT CONDITION PAST CONDITION
Sore Throats - Frequent (Age Resolved)
Hay Fever/Allergies N/A CURRENT CONDITION PAST CONDITION
Hay Fever/Allergies (Age Resolved)
Hoarseness - Prolonged N/A CURRENT CONDITION PAST CONDITION
Hoarseness - Prolonged (Age Resolved)
Pneumonia/Pleurisy N/A CURRENT CONDITION PAST CONDITION
Pneumonia/Pleurisy (Age Resolved)
Bronchitis/Chronic Cough N/A CURRENT CONDITION PAST CONDITION
Bronchitis/Chronic Cough (Age Resolved)
Asthma/Wheezing N/A CURRENT CONDITION PAST CONDITION
Asthma/Wheezing (Age Resolved)
Shortness of Breath (On Exertion) N/A CURRENT CONDITION PAST CONDITION
Shortness of Breath (On Exertion) (Age Resolved)
Shortness of Breath (Lying Flat) N/A CURRENT CONDITION PAST CONDITION
Shortness of Breath (Lying Flat) (Age Resolved)
Chest Pain N/A CURRENT CONDITION PAST CONDITION
Chest Pain (Age Resolved)
High Blood Pressure N/A CURRENT CONDITION PAST CONDITION
High Blood Pressure (Age Resolved)
Heart Murmur N/A CURRENT CONDITION PAST CONDITION
Heart Murmur (Age Resolved)
Swollen Ankles N/A CURRENT CONDITION PAST CONDITION
Swollen Ankles (Age Resolved)
Irregular Pulse N/A CURRENT CONDITION PAST CONDITION
Irregular Pulse (Age Resolved)
Palpitations N/A CURRENT CONDITION PAST CONDITION
Palpitations (Age Resolved)
Leg Pain - When Walking N/A CURRENT CONDITION PAST CONDITION
Leg Pain - When Walking (Age Resolved)
Varicose Veins/Phlebitis N/A CURRENT CONDITION PAST CONDITION
Varicose Veins/Phlebitis (Age Resolved)
Loss of Appetite - Recent N/A CURRENT CONDITION PAST CONDITION
Loss of Appetite - Recent (Age Resolved)
Difficulty Swallowing N/A CURRENT CONDITION PAST CONDITION
Difficulty Swallowing (Age Resolved)
Heartburn N/A CURRENT CONDITION PAST CONDITION
Heartburn (Age Resolved)
Peptic Ulcer N/A CURRENT CONDITION PAST CONDITION
Peptic Ulcer (Age Resolved)
Persis. Nausea/Vomiting N/A CURRENT CONDITION PAST CONDITION
Persis. Nausea/Vomiting (Age Resolved)
Abdominal Pain - Chronic N/A CURRENT CONDITION PAST CONDITION
Abdominal Pain - Chronic (Age Resolved)
Gall Bladder Trouble N/A CURRENT CONDITION PAST CONDITION
Gall Bladder Trouble (Age Resolved)
Jaundice / Hepatitis N/A CURRENT CONDITION PAST CONDITION
Jaundice / Hepatitis (Age Resolved)
Change in Bowel Habits (Diarrhea) N/A CURRENT CONDITION PAST CONDITION
Change in Bowel Habits (Diarrhea) (Age Resolved)
Change in Bowel Habits (Diverticulitis) N/A CURRENT CONDITION PAST CONDITION
Change in Bowel Habits (Diverticulitis) (Age Resolved)
Change in Bowel Habits (Constipation) N/A CURRENT CONDITION PAST CONDITION
Change in Bowel Habits (Constipation) (Age Resolved)
Change in Bowel Habits (Crohn’s/Colitis) N/A CURRENT CONDITION PAST CONDITION
Change in Bowel Habits (Crohn’s/Colitis) (Age Resolved)
Change in Bowel Habits (Bloody or Tarry Stools) N/A CURRENT CONDITION PAST CONDITION
Change in Bowel Habits (Bloody or Tarry Stools) (Age Resolved)
Hemorrhoids N/A CURRENT CONDITION PAST CONDITION
Hemorrhoids (Age Resolved)
Hernia N/A CURRENT CONDITION PAST CONDITION
Hernia (Age Resolved)
Urine Infections - Frequent N/A CURRENT CONDITION PAST CONDITION
Urine Infections - Frequent (Age Resolved)
Blood in Urine N/A CURRENT CONDITION PAST CONDITION
Blood in Urine (Age Resolved)
Kidney Stones N/A CURRENT CONDITION PAST CONDITION
Kidney Stones (Age Resolved)
Venereal Disease N/A CURRENT CONDITION PAST CONDITION
Venereal Disease (Age Resolved)
Urination (Decrease in Force/Flow) N/A CURRENT CONDITION PAST CONDITION
Urination (Decrease in Force/Flow) (Age Resolved)
Urination (Painful) N/A CURRENT CONDITION PAST CONDITION
Urination (Painful) (Age Resolved)
Urination (Overnight > than Twice) N/A CURRENT CONDITION PAST CONDITION
Urination (Overnight > than Twice) (Age Resolved)
Urination (Loss of Control) N/A CURRENT CONDITION PAST CONDITION
Urination (Loss of Control) (Age Resolved)
Urethral Discharge N/A CURRENT CONDITION PAST CONDITION
Urethral Discharge (Age Resolved)
Chronic Fatigue N/A CURRENT CONDITION PAST CONDITION
Chronic Fatigue (Age Resolved)
Weight Loss - Recent N/A CURRENT CONDITION PAST CONDITION
Weight Loss - Recent (Age Resolved)
Anemia N/A CURRENT CONDITION PAST CONDITION
Anemia (Age Resolved)
Bruise Easily N/A CURRENT CONDITION PAST CONDITION
Bruise Easily (Age Resolved)
Cancer N/A CURRENT CONDITION PAST CONDITION
Cancer (Age Resolved)
Diabetes N/A CURRENT CONDITION PAST CONDITION
Diabetes (Age Resolved)
Thyroid Disease N/A CURRENT CONDITION PAST CONDITION
Thyroid Disease (Age Resolved)
Seizures N/A CURRENT CONDITION PAST CONDITION
Seizures (Age Resolved)
Stroke N/A CURRENT CONDITION PAST CONDITION
Stroke (Age Resolved)
Tremor/Hands Shaking N/A CURRENT CONDITION PAST CONDITION
Tremor/Hands Shaking (Age Resolved)
Muscle Weakness N/A CURRENT CONDITION PAST CONDITION
Muscle Weakness (Age Resolved)
Numb/Tingling Sensation N/A CURRENT CONDITION PAST CONDITION
Numb/Tingling Sensation (Age Resolved)
Headaches - Frequent N/A CURRENT CONDITION PAST CONDITION
Headaches - Frequent (Age Resolved)
Arthritis/Rheumatism N/A CURRENT CONDITION PAST CONDITION
Arthritis/Rheumatism (Age Resolved)
Back Pain - Recurrent N/A CURRENT CONDITION PAST CONDITION
Back Pain - Recurrent (Age Resolved)
Bone Fracture/Joint injury N/A CURRENT CONDITION PAST CONDITION
Bone Fracture/Joint injury (Age Resolved)
Gout N/A CURRENT CONDITION PAST CONDITION
Gout (Age Resolved)
Osteoporosis N/A CURRENT CONDITION PAST CONDITION
Osteoporosis (Age Resolved)
Foot Pain N/A CURRENT CONDITION PAST CONDITION
Foot Pain (Age Resolved)
Cold Numb Feet N/A CURRENT CONDITION PAST CONDITION
Cold Numb Feet (Age Resolved)
Rashes N/A CURRENT CONDITION PAST CONDITION
Rashes (Age Resolved)
Hives N/A CURRENT CONDITION PAST CONDITION
Hives (Age Resolved)
Psoriasis N/A CURRENT CONDITION PAST CONDITION
Psoriasis (Age Resolved)
Eczema N/A CURRENT CONDITION PAST CONDITION
Eczema (Age Resolved)
Sleeping - Difficulty N/A CURRENT CONDITION PAST CONDITION
Sleeping - Difficulty (Age Resolved)
Depression N/A CURRENT CONDITION PAST CONDITION
Depression (Age Resolved)
Nervousness N/A CURRENT CONDITION PAST CONDITION
Nervousness (Age Resolved)
Memory Loss N/A CURRENT CONDITION PAST CONDITION
Memory Loss (Age Resolved)
Moodiness - Excessive N/A CURRENT CONDITION PAST CONDITION
Moodiness - Excessive (Age Resolved)
Mental Illness N/A CURRENT CONDITION PAST CONDITION
Mental Illness (Age Resolved)
Phobias N/A CURRENT CONDITION PAST CONDITION
Phobias (Age Resolved)
Rheumatic Fever N/A CURRENT CONDITION PAST CONDITION
Rheumatic Fever (Age Resolved)
Scarlet Fever N/A CURRENT CONDITION PAST CONDITION
Scarlet Fever (Age Resolved)
Chicken Pox N/A CURRENT CONDITION PAST CONDITION
Chicken Pox (Age Resolved)
Polio N/A CURRENT CONDITION PAST CONDITION
Polio (Age Resolved)
Mumps N/A CURRENT CONDITION PAST CONDITION
Mumps (Age Resolved)
Measles N/A CURRENT CONDITION PAST CONDITION
Measles (Age Resolved)
German Measles N/A CURRENT CONDITION PAST CONDITION
German Measles (Age Resolved)
Tuberculosis N/A CURRENT CONDITION PAST CONDITION
Tuberculosis (Age Resolved)
Herpes N/A CURRENT CONDITION PAST CONDITION
Herpes (Age Resolved)
SYMPTOMS / DISEASES 01:
SYMPTOMS / DISEASES 01 (Status) N/A CURRENT CONDITION PAST CONDITION
SYMPTOMS / DISEASES 01 (Age Resolved)
SYMPTOMS / DISEASES 02:
SYMPTOMS / DISEASES 02 (Status) N/A CURRENT CONDITION PAST CONDITION
SYMPTOMS / DISEASES 02 (Age Resolved)
DAY-TO-DAY oz. per week
cups per day
# of times per week
cig/day
# yrs
# yrs quit
MALES Please complete
MALES FEMALES Please complete
MENSTRUAL FLOW Menstrual Flow Days of Flow
Cycle Length
Date – 1st day of last period
NUMBER OF: Pregnancies
Abortions
Miscarriages
Live Births
Birth Control Method:
Birth Control Pill (Name):
FLUSHING / MENOPAUSE Date of Last PAP Test:
PAP Test Results Date of Last Mammogram:
Mammogram Test Results ePrescribing consent:
I agree that Pediatric Ophthalmic Consultants may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payors for treatment purposes.
PARENT/GUARDIAN SIGNATURE:* Would you like a copy of these forms emailed to you? Please enter email address where you would like these forms sent.
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