Dr. Harry Landrum, Optometric Physician

Dr. Harry Landrum, Optometric Physician

Patient Registration Information

Welcome to our office! Thank you for choosing our office for your eye care. Please take the time to complete this form accurately and completely. It helps us do the best job possible for you. This information is held in complete confidence as it is part of your permanent record, and will not be released to anyone unless you authorize its release in writing. Please ask the receptionist to read our HIPPA office policy. Check here if you would like to receive a copy at your visit. □. Please fill out the information on the back as well.

Last NameFirst NamePreferred (Nickname)Date of Birth

Address Social Security Number

CityStateZip Code

Home PhoneCell PhoneTexting ok?Work Phone

Email address (if any): ______

Please indicate your preferred methods at which to reach you: □ Text □ Email □ Phone

Referred by: ______

Occupation: ______Employer ______Hobbies: ______

I am: □ Single □Married □ Divorced □Legally Separated □ Widowed □ Domestic Partner

Date of last eye exam: ______Previous eye doctor, if applicable: ______

Primary Care Physician: ______Address (City/State): ______

Insurance Information

We REQUIRE all insurance information prior to services being provided. Due to the diverse nature of many eye conditions, disorders, and procedures, many of the services we provide are covered by your MAJOR MEDICAL INSURANCE rather than routine vision coverage. Please provide us with the following information even if you believe that you are seeing us for a non-medical reason.

Medical Insurance CompanyMember Number

Vision Insurance CompanyMember Number

Financial Policy Information

All Co-Payments and individual portions of your balance are due at the time of service. If you participate in any insurance plan, you are ultimately responsible for these amounts. Depending upon your coverage, we may bill your insurance directly for their portion. If we are not on your provider list, payment in full for all services and materials is due at time of service. We will provide you with a receipt to submit with your claim form directly to your insurance company. This will expedite the reimbursement of funds directly to you.

I authorize the release of any medical or other information necessary to process any claims arising from services and materials provided. I also request payment of government or private insurance benefits to the physician accepting assignment for services and materials provided. I also understand that I assume all financial responsibility for this account for any amounts due, regardless of insurance coverage.

Patient or Guardian SignatureDate

Medical History

1. What is your eye problem/complaint today? Please describe any changes in vision or any problems seeing, as best as you can.

2. How comfortable are your eyes? Please check any of the following that apply:

□ Eye discomfort □ Red □Watery □ Itchy □Crusty □ Tired □In need of frequent eye drops

Do you wear glasses? □ Yes □No Are you planning to get new glasses today? □ Yes □No □ If my RX changes

Do you wear contact lenses? □ Yes □No Are you interested in wearing contact lenses? □ Yes □No

Type of Contact Lenses: ______Are you planning to order contact lenses today? □Yes □No □ If my RX changes

Patient Ocular/Medical History / Yes / No / Social History / Yes / No
Glaucoma / Do you smoke?
Cataracts / If YES, do you smoke every day?
Macular Degeneration / If NO, did you used to smoke?
Eye Injury / Do you use recreational drugs?
Retinal Disease / Do you drink alcohol?
Loss of Vision/Blindness / Are you currently pregnant or nursing?
Eye Turn/Strabismus / How many hours a day do you use a computer?
Lazy Eye/Amblyopia / What is your current height?
Eye Infection / What is your current weight?
Dry Eye
High Blood Pressure/Hypertension
Diabetes / Patient Review of Health / Yes / No
Other Disease(s)/Prematurity / Do you currently have or ever had problems in the following areas?
Have you ever had a surgery on your eyes? / Constitution (Fever, Weight Gain/Loss)
If YES, what was it? Why did you have it performed? / Cardiovascular/Vascular (Diabetes, High Blood Pressure, Stroke)
Ears, Nose, Throat, Mouth (Allergies, Sinus Congestion, Dryness)
Respiratory (Asthma, Bronchitis, Emphysema)
Family Ocular/Medical History / Yes / No / Gastrointestinal (Diarrhea, Constipation)
Glaucoma / Genitourinary (Genitals, Kidney, Bladder Problems)
Cataracts / Musculoskeletal (Arthritis, Joint/Muscle Pain)
Macular Degeneration / Integumentary (Skin Problems)
Eye Injury / Neurological (Headaches, Migraines, Seizures)
Retinal Disease / Psychiatric (Mental/Emotional Problems)
Loss of Vision/Blindness / Endocrine (Thyroid/Other Gland Problem)
Eye Turn/Strabismus / Hematologic/Lymphatic (Anemia, Bleeding Problems)
Lazy Eye/Amblyopia / Allergic/Immunologic (Allergy)
Eye Infection
Dry Eye
High Blood Pressure/Hypertension / Medications
Other Disease(s)/Prematurity / List all medications that you currently take (including over-the-counter,
vitamins, supplements, and contraceptives, etc.)
Diabetes

What is your preferred pharmacy?______Phone Number: ______

Do you have any allergies to medications? ______

Do you have environmental allergies?______