Patient Demographic

Patient Name	This field is required This field is required
Gender
Parent or Legal Guardian	This field is
Date of birth	This field is required
Address	This field is required , This field is required , This field is required This field is required
Home Phone	This field is
Cell Phone:	This field is
Work Phone:	This field is
Can we text you? (Cell Phone Required)	YesNoThis field is required
Email:	This field is required\|email
Refered from:	This field is

I understand that you will bill my insurance as a courtesy to me. However, I also understand that I am ultimately responsible for the total amount due, should my insurance company decline to pay or if I do not have insurance. I understand that payment of at least half of my portion of the total bill (including any co-pays) is expected at the time services are rendered and before my glasses or my contacts will be ordered. I authorize my insurance company to make payment directly to the provider. If my insurance company pays me instead of the provider, when the provider should have received the payment, I agree to inform the provider and pay the amount owed in full. I am aware that there is a $25.00 returned check fee policy in effect in this office. I understand that if my account is delinquent at 120 days past service date, it may be turned over to collections. Should my account have to be turned over to collections, I agree to be responsible for any extra fees that this office might incur due to such a situation, including a $25.00 processing fee and any and all municipal charges. All Family Vision Care asks that you notify our office at least 24 hours in advance when you are unable to keep your scheduled appointment. A “no show” will result in a $25 charge to be added to your account. My signature on this form is acceptance of these terms and may also be used as the signature on file for insurance purposes. If I have any questions regarding any of this information I am free to inquire before my exam and before I place an order. Signature is required before an exam takes place and before an order is placed. Welcome to All Family Vision Care! Thank you for taking the time to fill out our patient demographic form.

Patient History

Medical Information

Date of last eye exam:

(If applies to you)

This field is

Were your eyes dilated?

YesNoThis field is required

How is your general health?

Do you take medications for any of these systems?

Gastrointestinal?	YesNoThis field is required	Nervous?	YesNoThis field is required	Endocrine/glands?	YesNoThis field is required	Ears/Nose/Throat?	YesNoThis field is required
Urinary?	YesNoThis field is required	Blood/Lymph?	YesNoThis field is required	Cardiovascular?	YesNoThis field is required	Muscles/Bones?	YesNoThis field is required
Allergic/Immunologic?	YesNoThis field is required	Respiratory?	YesNoThis field is required	Integumentary/skin?	YesNoThis field is required	Headaches?	YesNoThis field is required
High Blood Pressure?	YesNoThis field is required	Eyes?	YesNoThis field is required	Mental?	YesNoThis field is required	High Chollesterol?	YesNoThis field is required

Please Explain:

Diabetes:

YesNoThis field is required

Type:

This field is

Date Diagnosed:

This field is

Allergies to medication:

YesNoThis field is required

Reactions?

This field is

Do you use Cigarettes/Tobacco or other drugs?

This field is required

Which and how often?

This field is

Current Medication(s):

Have you had any operations?

YesNoThis field is required

When?

This field is

Name of family doctor and/or primary care physician:

This field is required

Date of last visit

This field is

Date your blood pressure was last checked

This field is no

Family History

High Blood Pressure?	YesNoThis field is required	Relation:	This field is	Macular Degeneration?	YesNoThis field is required	Relation:	This field is
Diabetes?	YesNoThis field is required	Relation:	This field is	Retinal Detachment?	YesNoThis field is required	Relation:	This field is
Glaucoma?	YesNoThis field is required	Relation:	This field is	Cataracts?	YesNoThis field is required	Relation:	This field is

Personal Eye Information

Do you have any eye conditions or problems?	YesNoThis field is required	Please explain:
Have you had any eye operations?	YesNoThis field is required	Kind:	This field is	Date:	This field is
Have you had an eye injury?	YesNoThis field is required	Type:	This field is	Date:	This field is
Do you have glaucoma?	YesNoThis field is required	Cataracts?	YesNoThis field is required	Dry eyes?	YesNoThis field is required
Macular degeneration?	YesNoThis field is required	Retinal detachment?	YesNoThis field is required	Blurred vision?	YesNoThis field is required
Do you wear glasses?	YesNoThis field is required	Contact lenses?	YesNoThis field is required	Type:	This field is

Additional Information?

HIPAA Release

Authorization to Disclose Health Information to Family Members and Friends

I authorize the release of health information to the individuals listed below:

Name	Relationship	Medical
		Information allowed to disclose(Check all that apply)
This field is	This field is
This field is	This field is
This field is	This field is
This field is	This field is
This field is	This field is

HIPAA Privacy Policy HIPAA Privacy Policy Acknowledgement: I acknowledge that I was offered a copy of Dr. Michael Klautzsch O.D., Dr. Justin Heintz O.D., and Dr. Kelly Shannon O.D. notice of privacy practices.

Patient Records Release Form

I, , authorize the release of the records listed below:

Eye Exam
Spectacle Prescription
Contact Lens History and Prescription
Any Additional Medical Records
Comment:

I have reviewed and I understand this authorization. I also understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected under Federal Law.

You have the right to revoke this authorization at any time, provided that you do so in writing. If you revoke your authorization, we will no longer use or disclose information about you for the reasons covered by your written authorization, we cannot take back any uses or disclosures already made with your permission. To revoke this authorization please contact All Family Vision Care directly, identifying the date you signed this authorization, the recipient of the information identified in this authorization, and state that you are revoking this authorization. This authorization will expire 90 days from the date of signing, or the end of the period reasonably needed to complete the disclosure of the above-described purpose.

Please Read Carefully

Your Form has not been submitted yet!

After you click "Submit," a download will be generated which you can save for your records. Your forms will be submitted to All Family Vision Care. At your next scheduled appointment, you will be asked to confirm that the information submitted is correct.

Doctors

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Actions

Please fill out all of the form fields as accurately as possible.

Please Read Carefully

Your Form has not been submitted yet!

After you click "Submit," a download will be generated which you can save for your records. Your forms will be submitted to All Family Vision Care. At your next scheduled appointment, you will be asked to confirm that the information submitted is correct.

Thank You!

Come in and see us at any of these four convenient locations!

All Family Vision Care

All Family Vision Care Bend

Raleigh Hills Vision Clinic

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Salem Vision Clinic

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Doctors

New Patient Form for: {{ demo.first_name }} {{ demo.last_name }}

Patient DemographicStatus: {{ demo_status }}

Patient HistoryStatus: {{ history_status }}

Patient HIPAAStatus: {{ hipaa_status }}

Patient Records ReleaseStatus: {{ records_status }}

Actions

Please fill out all of the form fields as accurately as possible.

Please Read Carefully

Your Form has not been submitted yet!

After you click "Submit," a download will be generated which you can save for your records. Your forms will be submitted to All Family Vision Care. At your next scheduled appointment, you will be asked to confirm that the information submitted is correct.

Thank You!

Come in and see us at any of these four convenient locations!

All Family Vision Care

All Family Vision Care Bend

Raleigh Hills Vision Clinic

Eye Impressions

Salem Vision Clinic

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Staff

Services

Eye Conditions

Products

Patient Resources

Blog