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New Patient Information

Name
Address
Local Pharmacy Address:
Gender
Race
Is patient enrolled in Hospice?

If seen by us for a worker's compensation injury:

In order to comply with federal regulations regarding your privacy in our office, we ask that you complete the following questions:
How can we communicate APPOINTMENT information?
How can we communicate MEDICAL information?

Please provide the name and relationship of the specific person(s) with whom we may share patient information (medical, billing, and appointments) about you. This information will only expire when requested by the patient.

Name
Name
Name
Reason for Today's Visit
Would you like to be checked for a new eyeglass prescription today?
Is your current problem injury related?
Cause of Injury

Medical History (please check yes or no)

Heart Disease
Cancer
Mitral Valve Prolapse
Rheumatoid Arthritis/Lupus
Problem with Anestheia
Ulcers/Stomach Problems
Hemophilia/Bleeding Problems/Anemia
Nervous/Mental Disorder/Depression
Unusual Childhood Disease (measles, mumps, etc.)
Blood Clot/DVT/Pulmonary Emulsion
Diabetes
Thyroid Disease
High Blood Pressure
Kidney Disease
Hepatitis/Liver Disease
HIV/AIDS
Epilepsy/Seizures
Cholesterol
Venereal Disease
Asthma/Respiratory Disease/TB
Family Eye History (check all that apply)
Do you drive?
If so;
Social History
Alcohol Use
Tobacco Use

THE ABOVE INFORMATION IS CORRECT AND WAS FILLED OUT TO THE BEST OF MY ABILITY:

(Parent signature if patient is a minor)