Patient Information

Patient's name:*

First Middle Last

Reason for today's visit:*

Is this your legal name?*

Yes
No

If not, what is your legal name?*

First Middle Last

Former name:

First Middle Last

Birthdate:*

MM

DD

YYYY

Age:*

Gender:*

Male
Female

Address:*

Street Address Address Line 2 City State ZIP Code

Email Address:

Home phone no.:

Occupation:

Employer:

Employer phone no.:

Preferred method of communication:*

Call
Text
Email

May we leave a message?*

Yes
No

Emergency Contact Name:*

Emergency Contact Phone:*

Primary Care Physician:

Preferred Pharmacy Name:

Preferred Pharmacy Location:

Who may we thank for referring you?

Family
Friend
Other

Name:

Health History

Medical History

If other, please specify:

Are you pregnant or nursing?*

Yes
No

Do you use any of the following tobacco products?

Cigarettes
Pipe
Cigars
Smokeless Tobacco
Other

Amount:

Do you have diabetes?*

Yes
No

Year of diabetes diagnosis*

Type 1 or 2*

Is it stable or unstable*

What was your last A1C?*

Please list any allergies, including environmental and drug related:

Ocular History

If other, please specify:

Do you wear contact lenses?*

Yes
No

Do you sleep in your lenses?*

Yes
No

How often do you change your contact lenses?

Are you having dryness and discomfort with your lenses?

What contact lens solution do you use?

Family Medical and Ocular History

(Parents, Grandparent, Siblings)

If other, please specify:

Please list any current medications including vitamins, topical and eye drops or provide a list for us to copy:

Insurance Information

(Please give your insurance card to the receptionist.)

Policy holder’s name:

First Last

Birth date:

MM

DD

YYYY

Policy holder’s social security no.:

Patient’s relationship to subscriber:

Self
Spouse
Child
Other

Please indicate primary insurance:

Vision Service Plan
Eyemed
Medical Mutual
Aetna
Medicare
Vision Plus
Anthem
Other

Financial Agreement

In order to control the cost of billing, we ask that the patient’s portion is paid at the time services are rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance, any account 90 days past due are subject to collections fees. There will be a service charge on all returned checks.
Payment from my insurance company is to be paid directly to Dr. Kristin Campbell, Dr. Misty Bauder and/or Dr. Carrie McMahon. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.

Patient or Guardian Signature*

Date*

Authorization to Obtain Information

Is there a friend or relative authorized to obtain information about you?*

Yes
No

Name of Authorized Person:

Relationship of Authorized Person:

Patient or Guardian Signature*

Date*

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have received a copy of the notice of privacy practices by Dr. Kristin Campbell’s Office. I understand that a copy of this notice is available to me anytime at my request.

Patient's name:*

First Middle Last

Patient or Guardian Signature*

Date*

Medical Registration Form

Medical Registration Form

Patient Information

Health History

Insurance Information

Financial Agreement

Authorization to Obtain Information

Acknowledgement of Receipt of Notice of Privacy Practices

Eye Doctor in Delaware, OH

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Kristin L. Campbell, O.D.