Demographic Form

Demographic Form

Date of Birth (Required)

Gender

Marital Status

Address

PLEASE PROVIDE 2 PREFERRED PHONE NUMBERS WHICH WE MAY USE TO CONTACT YOU

Opt-in for phone calls/emails/texts

Insurance Information

Important Note: Please provide your vision and medical insurance cards to the receptionist. if you do not provide us with complete insurance information at the time of your initial vision, we will be unable to bill your insurance company. You are then responsible for payment at the time of service.

Primary Vision

Insured Member's DOB

Primary Medical

Insured Member's DOB

Personal Medical History

Do you have, or are you taking medication to treat the following medical conditions? Please indicate if you have ever had, any of the following medical conditions.

Constitution

Ear, Nose, Throat

Neurological

Psychiatric *

Cardiovascular *

Respiratory *

Gastrointestinal *

Genitourinary *

Muskuloskeletal *

Integumetary *

Endocrine *

Hemotologic/Lymphatic *

Allergy/Immunology *

List medications

List surgeries (include dates if possible)

Personal Ocular History

Eye Injury or surgery *

Strabismus(eye turn) *

Amblyopia (lazy eye) *

Double Vision​​​​​​​ *

Cataracts​​​​​​​ *

Glaucoma​​​​​​​ *

Macular Degeneration​​​​​​​ *

Dry Eyes​​​​​​​ *

Excessive Tearing​​​​​​​ *

Spots, Halos, Flashes​​​​​​​ *

Sudden Loss of Vision​​​​​​​ *

Wear contact lenses/glasses​​​​​​​ *

Other​​​​​​​ *

Date of last Eye Exam/previous Eye Doctor

Explanation of any Eye Injury or Surgery

Do you have any allergies?​​​​​​​ *

Do you have any allergies to medications?​​​​​​​ *

Name of your physician

Office location

Preferred Pharmacy Location

Social History

Tobacco use *

Drug use *

Alcohol use *

Exposure to HIV, Hepatitis or TB​​​​​​​ *

Hobbies

Family History

Please note any immediate family members (parents, siblings, children) with the following conditions

Cancer *

Diabetes *

High Blood Pressure *

Thyroid Disease *

Cataracts​​​​​​​ *

Glaucoma​​​​​​​ *

Macular Degeneration​​​​​​​ *

Strabismus​​​​​​​ *

Blindness​​​​​​​ *

Other *

I am resonsible for payment for all services and materials provided by Arsulowics Eye Care not covered by an insurer. My signature serves as a "signature on file" for claim processing and for the release of medical information to my insurance carriers

I authorize Arsulowicz Eye Care the permission to release my medical records to other health care providers or insurance companies to further enhance my eyecare well-being and for billing procedures.

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