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Name *

First

Middle

Last

DOB *//

Social Security #

Marital Status *

Gender *

Female
Male
Other

Street Address/PO Box *

City, State, Zip *

Home/Cell Number *

First

Last

Email

Primary Care Dr.

Referring Dr.

Pharmacy/City

Pharmacy Phone

Employer/Occupation *

Current Medical Insurance(s)

Policy Holder Name

DOB//

How did you hear about Dr. Rom:

Emergency Contact Information

Name/Relationship *

First

Last

Home Phone *

Cell Phone *

I certify that I, and/or my dependants(s), have insurance coverage with those listed above and assign directly to Insight Eye Center, Dr. Michael E.Rom, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsble for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named practice may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable to related services. I acknowledge that I understand the Privacy Policies of this office. (A copy of the Notice of Privacy Practices is available upon request.) *

I Accept

Patient Signature: *

Date: *//

Medical History

Date *//

Patient Name: *

First

Last

DOB: *//

Date of last eye exam://

Is there any Family History (including yourself) of:

Glaucoma
Macular Degeneration
Cataracts

(Above) If yes, who

Have you ever had an eye operation or serious injury? *

Yes
No

If yes, explain

List Any Other Medical Conditions:

Smoking Status: *

Non Smoker
Current Smoker
Previous Smoker

Do you drink Alcoholic Beverages?

Frequency:

Do you use any recreational drugs?

Please List:

List all Prescriptions Medications that you take:

List all OTC Medications, Herbal Supplements, or Vitamins that you take:

Are you allergic to any Medications/Anesthetics/Foods: *

Yes
No

Please List:

Patient Signature: *

Date / Time *//

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Emergency Contact Information

Medical History

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