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.


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)
This field is required
Email:
This field is required|email
Refered from:
This field is
Patient History
Medical Information
Date of last eye exam: (If applies to you)
This field is
Were your eyes dilated?
This field is required
How is your general health?
Do you take medications for any of these systems?
Gastrointestinal?
This field is required
Nervous?
This field is required
Endocrine/glands?
This field is required
Ears/Nose/Throat?
This field is required
Urinary?
This field is required
Blood/Lymph?
This field is required
Cardiovascular?
This field is required
Muscles/Bones?
This field is required
Allergic/Immunologic?
This field is required
Respiratory?
This field is required
Integumentary/skin?
This field is required
Headaches?
This field is required
High Blood Pressure?
This field is required
Eyes?
This field is required
Mental?
This field is required
High Chollesterol?
This field is required
Please Explain:
Diabetes:
This field is required
Type:
This field is
Date Diagnosed:
This field is
Allergies to medication:
This 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?
This 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
Family History
High Blood Pressure?
This field is required
Relation:
This field is
Macular Degeneration?
This field is required
Relation:
This field is
Diabetes?
This field is required
Relation:
This field is
Retinal Detachment?
This field is required
Relation:
This field is
Glaucoma?
This field is required
Relation:
This field is
Cataracts?
This field is required
Relation:
This field is
Personal Eye Information
Do you have any eye conditions or problems?
This field is required
Please explain:
Have you had any eye operations?
This field is required
Kind:
This field is
Date:
This field is
Have you had an eye injury?
This field is required
Type:
This field is
Date:
This field is
Do you have glaucoma?
This field is required
Cataracts?
This field is required
Dry eyes?
This field is required
Macular degeneration?
This field is required
Retinal detachment?
This field is required
Blurred vision?
This field is required
Do you wear glasses?
This field is required
Contact lenses?
This 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:
Information allowed to disclose(Check all that apply)
Name Relationship Medical Billing Make/ Cancel
Appointments
Pick up/ Place
orders
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:
  • 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.

Thank You!

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