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Patient Demographic
Patient Name
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Gender
Parent or Legal Guardian
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Date of birth
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Address
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Home Phone
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Cell Phone:
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Work Phone:
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Can we text you? (Cell Phone Required)
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Email:
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Refered from:
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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)
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Were your eyes dilated?
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How is your general health?
Do you take medications for any of these systems?
Gastrointestinal?
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Nervous?
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Endocrine/glands?
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Ears/Nose/Throat?
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Urinary?
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Blood/Lymph?
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Cardiovascular?
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Muscles/Bones?
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Allergic/Immunologic?
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Respiratory?
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Integumentary/skin?
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Headaches?
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High Blood Pressure?
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Eyes?
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Mental?
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High Chollesterol?
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Please Explain:
Diabetes:
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 Type:
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Date Diagnosed:
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Allergies to medication:
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 Reactions?
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Do you use Cigarettes/Tobacco or other drugs?
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 Which and how often?
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Current Medication(s):
Have you had any operations?
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 When?
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Name of family doctor and/or primary care physician:
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Date of last visit
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Date your blood pressure was last checked
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Family History
High Blood Pressure?
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Relation:
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Macular Degeneration?
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Relation:
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Diabetes?
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Relation:
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Retinal Detachment?
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Relation:
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Glaucoma?
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Relation:
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Cataracts?
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Relation:
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Personal Eye Information
Do you have any eye conditions or problems?
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Please explain:
Have you had any eye operations?
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Kind:
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Date:
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Have you had an eye injury?
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Type:
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Date:
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Do you have glaucoma?
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Cataracts?
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Dry eyes?
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Macular degeneration?
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Retinal detachment?
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Blurred vision?
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Do you wear glasses?
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Contact lenses?
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Type:
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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
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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.

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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.

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

Salem

Salem Vision Clinic

Tel: 503-364-0767

Sherwood

Eye Impressions

Tel: 503-625-0733

Corvallis

All Family Vision Care

Tel: 541-757-8844

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