Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax or mail them if at all possible before your appointment. This will speed up your check in time and give us a brief background on you and your visual history. Please bring your current eyewear, including sunwear, contact lenses, and box or container with specifications of the contact lenses. If is important that you bring a drive with you if at all possible, as your eyes will be dilated. If you have any questions prior to your appointment or need directions, please don t hesitate to call us or use the locator on our website. Again we look forward to meeting you. Sincerely, Lawrence E. Hannon, M.D.
Patient Information Name: DOB: Sex: M F Age Address: City: State: Zip: Home Phone: Cell: SSI# (If patient is under the age of 18) Name of guardian: Primary Care Physician: Phone#: Address: City: State: Zip: How did you hear about us?: Email Address: Patient Employment: Emergency Contact: Work Phone: Employer: Occupation: Name: Phone: Relationship: If Yes, please give name(s) and relationship to you: Please list the preferred phone number to call you regarding any financial, insurance or medical information: May we leave voice mail? YES Are there any family member(s) we can speak to regarding your medical information? YES Whom? Insurance Information The information below must be completely filled out and insurance card must be present at the time of service. ARE YOU the patient THE PRIMARY INSURANCE HOLDER? YES Whom If please provide the following information about the primary insurance holder. Name: Relationship to you the patient: DOB: SSI#: Primary Insurance: Secondary Insurance: Address: Address: Phone: Phone: ID#: Group# Id# I herby assign benefits for all medical/surgical expenses to Lawrence Hannon, M.D. I understand that I am financially responsible for all charges not covered by this assignment of benefits, and for all co-pays and deductibles. I also authorize release of medical information to an insurance company, medical facility of physician. Patient Signature of legal guardian: Date:
Patient History Form Date: Last Name: First Name: MI: Marital Status: Single Divorced Married Widow/Widower Who Lives With You? Employer: Occupation: What Kind of Work? Do you have any allergies to any medications? YES, If yes, please list: Review of Systems Have you ever had problems with any of the following. Please explain any yes answers on the next page provided. System YES SYSTEM YES SYSTEM YES SYSTEM YES Gastrointestinal Cardiac Neurological Macular Degeneration Rectal Bleeding High Blood Pressure Seizures Amblyopia (lazy eye) Irritable Bowel Pacemaker Weakness Crohn s Disease Irregular Heartbeat Migraines Ear, Nose & Throat Trouble Swallowing Chest Pain Environmental Allergies Heartburn Stroke Musculoskeletal Sinus Problems Abdominal Pain Osteoporosis Deafness Respiratory Muscle Disease Hepatic Asthma Arthritis Psychosocial Liver Disease Pneumonia Neck Pain Alcoholism Hepatitis Emphysema Back Pain Substance Abuse Pancreatitis Chronic Cough Blood Disorders Depression Skin Genitourinary Gout Rash Kidney Disease Ophthalmic (eye) Bruises Endocrine/Metabolic Diabetes Cholesterol Thyroid Disorders Eye Laser Surgery Cataracts Glaucoma Diabetic Retinopathy Blindness Anxiety Disorders Please list below any symptom or disease not listed above?: Please explain any yes answers to the Review of Systems here:
Past History Have you ever had an eye injury or Surgery? YES Surgeries Dates Eye Injury Dates Are you currently or have you ever used, alcohol products? YES How many drinks? Per Day Per Week Per Month Are you currently of have you ever used Tobacco products? Are you or have you ever used, recreational drugs? Are you currently taking any medications or drugs (including over-the-counter, prescription, birth control pills)? YES How many packs per day? How many packs per year? If Yes, what kind? YES For how long? YES Medication Dose Times For How Long? Are you currently using eye drops? Yes Family History: Please indicate if your parents, brothers, sisters and/or children have had any of the following conditions: Condition Relation to Patient Condition Relation to Patient Condition Relation to Patient Diabetes Glaucoma Amblyopia (lazy eye) Cancer Macular Degeneration Retinal Detachment Heart/High Blood Pressure Cataracts Person Completing This Form/Relationship to Patient Date: Reviewed by Provider Date:
Contact Lens Fitting A contact lens evaluation is a separate part of a comprehensive eye examination. All contact wearers and new contact lens patients will require a contact lens evaluation and a contact lens fitting fee, even if the Rx does not change. A contact lens evaluation considers the health of your eye and how wearing contact lenses will affect your eye health, the determination of the prescription for maximum visual acuity, and review of proper lens alignment with your cornea and lid. The fee for contact lens evaluation will vary depending on several factors including whether you are being fit for the first time of have not worn contact for several years or if you are currently wearing contacts. Additional factors considered are the type of contact lenses that you are prescribed such as gas permeable lenses, soft lenses, whether you have astigmatism correction, or need bifocal lenses. The contact lens fitting fee includes: trial lenses and follow up contact lens checks within 30 days of your contact lens fit. Contact lens prescriptions are valid for 1 year and expire 1 year from t he date of your examination. I have read and understand that there is a separate fee for contact lens evaluation and fitting. Signature: Date:
Consent Clinical Diagnosis and Treatment Patients Name: Date of Birth: I,, do hereby give consent to the clinical staff of Lawrence E. Hannon II, MD to examine, treat and counsel me. I understand that there are certain hazards and risks connected with all forms of treatment and my consent is given with this knowledge. Signed: Date: Relationship to patient: Certified by the American Board Ophthalmology Phone 303-770-7100 Fax 303-770-7591 Receipt of Privacy Practices I hereby acknowledge receipt of the Notice of Privacy Practices Signed: Date: Relationship to patient: Certified by the American Board Ophthalmology Phone 303-770-7100 Fax 303-770-7591
Visual Lifestyle Questionnaire In order to provide the best eye care for you, it is important that we understand how you use your eyes, eyeglasses and contact lenses in your daily activities. Please help us by completing this questionnaire. Name: Date: Occupation: 1. Which of the following activities do you participate in? Reading Daily Frequently Occasionally Watching TV Daily Frequently Occasionally Driving Daily Frequently Occasionally Sports/Exercise Daily Frequently Occasionally Computer: Hours per day Hobbies: Sports: 2. How many pairs of glasses do you currently use? 3. Time spent outdoors? Seldom Occasionally Every chance I get 4. Are you bothered by glare from any of the following situations? Car Headlights Night Driving Snow Sunshine Computer Monitor Traffic Lights Fluorescent Lights 5. Is safety protection a concern? 6. Do you have metal or silicon allergies? 7. What do you like about your current glasses or contacts? (color, style, fit, etc.): 8. What don t you like about your current glasses or contacts? (weight, thickness, glare, etc.):
Authorization for Release of Identifying Health Information Patient Name: Patient Number: Patient Address: Patient Phone Number: I authorize the professional office of my optometrist named above to release health information identifying me and including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services under the following terms and conditions: 1. Detailed description of information to be released: 2. To whom may the information be released: 3. The purpose(s) for the release (if authorization is initiated by the individual, it is permissible to state at the request of the individual as the purpose, if desired by the individual): 4. Expiration date or event relating to the individual or purpose for the release: It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form. When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, sate of federal law changes this possibility. I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIXE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM. Dated: Patient Signature: If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form: Relationship to Patient: Print Name: Source of Authority:
Policy and Procedures Lawrence Hannon, MD Effective Date: 03/29/2010 Policy: No Show / Cancellation Policy All patients will be made aware of the patient contract. When scheduling an appointment, the receptionist will remind the patient of this policy. If a patient cancels within the 24 hours of fails to keep an appointment, billing will be notified and a fee of $35.00 will be charged. If there are extenuation circumstances the physician will have the discretion of whether or not to assess the fee. If a check is returned, a services charge of $30.00 will be added to your account. Signature: Date: