Form – Ophthalmologist Ogden

Patient Form

English

Spanish

English

Spanish

Patient Form

Acknowledgement Form

First Name *

Last Name *

Signature

Date

List of those who have my permission to access to my medical information

Name

Relationship

Name

Relationship

Name

Relationship

Patient Information

Date

Name *

Middle Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Employer

Date of Birth

Age

Sex

Male Female

Marital Status

Single Married Divorced Widowed

Language

Race

Ethnicity

Email Address *

Pharmacy

Location

Primary Care Physician

Phone

Referred By

Primary Insurance

Insurance

Group

Policy Holder Name

D.O.B

Sex

Relationship to Insured

Policy Holders Employers

Secondary Insurance

Insurance

Group

Policy Holder Name

D.O.B

Sex

Relationship to Insured

Policy Holders Employers

Emergency Contact

Name First

Last Name

Relationship To Patient

Address Line 1

Address Line 2

State

City

Zip

Home Phone

Cell Phone

Work Phone

Authorization For Treatment and Financial Agreement

I have read and agree to the Terms of Service Agreement listed below

I authorize treatment of the person named as patient and agree to pay for all services rendered to patient including but not limited to any amounts not paid by my insurance company. I will be responsible for all copayments ,deductibles,coinsurance,refraction fees and/or non-covered services. I request payment of authorized benefits.

All deliquient account will be charged an interest rate of 1.5% per month (18% per annum). In the event any balance is not paid as agreed, the undersigned agrees to pay all collection fees. In the event of a lawsuit to collect the unpaid balance ,the undersigned further agrees to pay court costs and reasonable attorney fees. You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by sending text message or e-mails, using any email address you provide to us. Method of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable

Section Divider

First Name

Last Name

PLEASE FILL OUT ENTIRE PAGE COMPLETELY

Respiratory

Cough Congestion Wheezing Asthma

Blood/Lymphnodes

Easy Brusing Gums Bleed Easily Prolonged Bleeding Heavy Aspirin Use

Gastrontestinal

Heart Burn Nausea/Vomiting jaundice/Hepatitis

Musculo Skeletal

Stiffness Arthritis Joint Pain/Swelling

Ear, Nose & Throat

Hard Of Hearing Ringing In Ears Vertigo

Genito-Urinary

Pain/Difficulty Blood In Urine History of Kidney Stones History Of STD’s

Skin

Rash/Sores Lesions Hives/Eczema

Psychiatric

Anxiety/Depression Mood Swings Difficulty Sleeping

Neurological

Seizures Weakness/Paralysis Numbness Tremors

Constitutional

Fatigue/Weakness Fever Weight Gain/Loss Fall Risk

Allergies

Past Eye History

Past Eye Surgeries

Current Eye Medications

If Yes, what type?

Yes No

If Yes, what Surgeries?

Current Medications

Blood Thinners Diabetic Medication Other Medications

If Yes, Please List

Smoking Status

Never, Smoked Current, Everyday Occasional Smoker Former Smoker

Alcohol

Yes No

If Yes, How much?

Illegal Drugs Used

How Much?

How Long?

When Quit?

By signing below you verify that the information listed is correct and up-to-date

Signature

Date

Time

Clayson Williams Eye Center offers a complete range of eye care services including LASIK and PRK refractive surgery, eye exams, vision testing for glasses and contacts.

Patient Form

Patient Form

Primary Insurance

Secondary Insurance

Emergency Contact

Authorization For Treatment and Financial Agreement

PLEASE FILL OUT ENTIRE PAGE COMPLETELY

Contact Info

Services

Opening Hours

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