Insured Party Information (please complete if the insurance is not in your name)

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1 Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr / Miss / Mrs / Mr Street Address: City: State: Zip Code: Social Security Number: - - Sex: M / F Single / Married / Widowed / Divorced Date of Birth: Age: Address: Home Phone: Cell Phone: Employer: Occupation: Employer s Phone: Fax: Insured Party Information (please complete if the insurance is not in your name) Date of Birth: Relationship: Street Address: City: State: Zip Code: Employer: Phone: Emergency Contact Information Phone: ( Phone: ( ) - Relationship: ) - Relationship: Insurance Information Medical Insurance: Primary Company Primary Contract No.: Group No.: Secondary Company Secondary Contract No.: Group No.: Do you have an insurance plan specifically for vision coverage? YES / NO If so, who is your vision plan provider? ALL PATIENTS: I understand that the charges made by the Alabama Vision Center for professional services may not be covered in full by any insurance covering such services to the patient. The patient and/or the party responsible for payment of fees for services rendered to the patient agree to make payment in full to the Alabama Vision Center in such cases. The undersigned accepts the fee charged as a lawful debt and promises to pay said fee including up to 35% of the debt for the cost of collection, in addition to attorney s fees, and court costs if such be necessary, waiving now and forever the right to claim exemption under the constitution and laws of the state of Alabama or any other state. I understand that I am required to pay any health insurance deductibles, co-insurance, co-payments, or any other charges incurred which are not paid by insurance. I understand that Medicare, Blue Cross and other insurances may or may not cover refractions, after hours services or other services that the doctor feels will be necessary for the treatment of my condition and/or maintenance of good health. If I receive a refraction, receive care after hours or other non covered service by my insurance today and any visits in the future, I do agree to pay for these services in full. I authorize release of any medical information necessary to process an insurance claim and wish to receive updates in medical information via . All payments are due at the time services are rendered. SIGNATURE: DATE: If you are an established patient, please add any new information above or sign below if your information has not changed. SIGNATURE: DATE:

2 Alabama Vision Center Referral Information Form Date of Birth: Dr. Established Patient Dr. Newspaper Cataract Ad Newspaper Flu Shot Ad AVC Newsletter Groupon Living Social Exam Living Social LASIK BabyPalooza New Patient Flyer Television ad Radio Facebook Helena City News Pelham City News Patient Referral LASIK patient referral exam YMCA Board Greystone Newsletter Other MCA Board YMCA Refractive Information Request Form I would like to request information on LASIK and refractive surgery I would not like to receive information on LASIK and refractive surgery Prescription: (may be filled out by your eye doctor) Right Eye: - x Left Eye: - x Contacts Y / N Soft / Hard Additional Comments Patient Signature Price Kloess M.D. Andrew Velazquez M.D. Randall Pitts M.D. Audrey Richards O.D. Holly Young O.D. Brittany Mitchell, O.D.

3 Alabama Vision Center, L.L.C. Patient Medical History Patient s Primary Care Physician & Phone # Pharmacy name & phone # Drug Allergies: Use of Alcohol: Yes No Date of Birth: Use of Tobacco: Yes No Check all that apply: Eyes: Blurred vision Cataracts Double vision Dryness Injury Floaters Glaucoma Infection Flashes of light Poor night vision Redness Itching Tearing Lazy eye Retinal Disease General: Fever Weight Loss Loss of appetite Fatigue Skin: Rash Itching Redness Shingles Ent: Deafness Sinus Problems Respiratory: Shortness of breath Asthma Sleep Apnea Allergies Cardiovascular: High Blood Pressure High Cholesterol Heart Attack Murmur Abnormal Valve Gastrointestinal: Acid Reflux Hepatitis Ulcers Hernia Cancer Genitourinary: Kidney Disease Kidney Stones Cancer Prostate Disease Musculoskeletal: Arthritis Lupus Muscle Aches Rheumatic Disease Neurological: Migraines Headache Seizure Vertigo Stroke Endocrine: Diabetes Type I or Type II Thyroid Disease Psychiatric: Anxiety Depression Hematology: Anemia Bleeding Disorder AIDS or HIV Other: Prior Surgeries: Name of all medications & dosage (or provide a list): Family History of: Eye Disease Heart Disease Diabetes Cancer Patient Signature: If you are an established patient, please add any new information above or sign below if your information has not changed. Patient Signature:

4 Alabama Vision Center, L.L.C. Acknowledgement of Privacy Notices Our privacy practices have been posted in our office for your convenience. We also have copies of our privacy practices available upon request. There are certain occasions when family members, friends or others might be involved in your care as a patient and you will want our office to be able to communicate directly with them. In order to protect the privacy of your personal health information, please share with us the names of any other people with whom we can discuss your care and share your protected health information. Please list below any other people with whom you authorize our office to discuss aspects related to your care. It is the responsibility of the patient to notify this office of any changes to the above information. Your signature below confirms you have read, understand, and agree to your privacy practices. Please sign and print your name and date this acknowledgement/authorization form. Return your signed acknowledgement/authorization to the receptionist. Signature: Print

5 Alabama Vision & Hearing Center, LLC First Name Last Name Account # Age Date Alabama Vision & Hearing Center now includes a full hearing evaluation as a part of the total care package that we offer to our valued patients. During your exam you will have a hearing pre- screening done at no charge. If the doctor feels you need to have a further evaluation, we can schedule a visit for you with our staff audiologist. 1. Do others complain that you watch television with the volume too high? 2. Do you frequently have to ask others to repeat themselves? 3. Do you have difficulty understanding what is being said when in groups or noisy situations? 4. Do you have to sit up front in meetings, church, or other social gatherings in order to understand the speaker? 5. Do you have difficulty understanding women or young children? 6. Do you have trouble knowing where sounds come from? 7. Are you unable to understand when someone talks to you from another room? 8. Have others told you that you don t seem to hear them? 9. Do you avoid family gatherings or social situations because you can t understand? 10. Do you have ringing or noises (tinnitus) in your ears? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No If you have answered yes to even one of these questions, you should have your hearing evaluated by our staff audiologist and take steps now to educate yourself about lifestyle changes you can make to slow the progression of hearing loss. For Administrative Use Only Doctor Pass R Circle Frequencies Failed Technician Fail L Appointment Notes

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