NEW PATIENT INFORMATION

Patient Name: _____________________________________________________________ Today’s date: ___/____/____(Last) (First) (Middle)

Date of Birth: ______/_______/_______ Age: _______ M F Social Security # ____-____-______

Address: _____________________________________________________________________________________________ Street Unit City State Zip

Telephone: Home: (_____) __________________ Cell: (______) ____________ Work: (______) ____________________

Email: _______________________________________________________________________________________________

Spouse’s Name: _________________________________Date of Birth _____/______/_____ Phone: (_____) ____________

Complete if under 18 years of age or a student:

Name of Legal Guardian: ______________________________________ Phone: (______) _________________________

Insurance Information:

Primary Insurance: Subscriber’s Name: ____________________________________________________ Date of Birth: ____________________

Secondary Insurance:Subscriber’s Name: ____________________________________________________ Date of Birth: ____________________

Vision Insurance: ____________________________________________Policy number# _____________________________

Emergency Contact: ________________________________ Phone: (______) ___________ Relationship______________

FINANCIAL ASSIGNMENT/AGREEMENT AND OTHER INFORMATION:

Referrals are required for all HMO and Worker’s Compensation patients.If you have insurance coverage, we will make our best efforts to coordinate your benefits. By signing this document, you acknowledge that you understand that you are financially responsible for all charges

incurred, including any co-payment, deductible or remaining balances after payment from your insurance carrier.You also authorize the release of any medical information necessary to process any medical claims, and understand that if you have an HMO, it is your responsibility to obtain all referrals for services rendered with our physicians.

In an effort, to best serve the scheduling of our patients, any office visits not cancelled less than 24 hours in advance will incur a $35 charge.

I am aware of the charge for refraction (measure for eyeglasses) is $45.00 and may not be covered by my insurance. I allow fax transmittal of my medical records if medically necessary. I consent to have my eyes dilated for my exam if the doctor deems it necessary. I understand that this can affect my

vision and my ability to drive a car or perform other functions dependent on my vision.

Patient Signature or Parent if Minor Date

Medical History Questionnaire

Patient Name: _________________________________________________ Today’s Date: ________________________

Date of Birth: _______/________/________

Languages Spoken: English Spanish Polish Other: ____________________________________________

Who is your primary doctor? ____________________________________________________________________________

What is the main reason for your visit today? _______________________________________________________________

Are you experiencing any of the following: None Blurred Vision Eyelid Growth Headaches Eye Pain Glare or Halos around lights Itching or Burning Frequent Tearing or Crusting Dry Eyes Floaters or Flashing Foreign body sensation Frequent Red Eyes Double Vision Other ____________________________________________________________________________________________

Medical History: None Diabetes Hypertension Heart Disease Lung Disease Kidney Disease Thyroid Disease Anemia High Cholesterol Cancer AIDS/HIV Stroke Dizziness Arthritis Allergies Other: ________________________________________________________________________________________

Ocular History: None Cataracts Glaucoma Macular degeneration Crossed Eyes or Lazy Eye Serious Eye Injury Iritis or Uveitis Retinal Detachment Diabetic Eye Disease

Other ___________________________________________________________________________________________

Previous Eye Surgeries: None Cataracts Glaucoma Pterygium Laser LASIK

Other: _____________________________________________________________________________________________

Current Medications: None ________________________________________________________________________

___________________________________________________________________________________________________

Eye medications: None Artificial Tears Other: _______________________________________

Medication Allergies: ________________________________________________________________________________

Family History: None or Not sure Cataracts Glaucoma Diabetic Eye Disease Macular Degeneration Blindness Iritis or Uveitis

Other ___________________________________________________________________________________________

Please indicate if you use the following substances:

Tobacco Never Rarely Daily (amount)Alcohol Never Rarely Daily (amount)Drugs Never Rarely Daily (amount)

Are you looking for new eyeglasses? Yes Not interested

Would you like to wear contact lenses? Yes Not interested

What was the approximate date of your last eye exam? ____________________________________________

2222 W. Division St. #135Chicago, IL 60622P: 773-376-2020F: 773-376-2227

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT&

PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Patient Name: _____________________________Date of Birth: _______/________/________

I have received and understand this practice’s Notice of Privacy written in plain language.

The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights and the practice’s legal duties with respect to my information.

I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices and to make changes regarding all protected health information resident at or controlled by this practice. If changes to the policy occur, this practice will provide me a revised Notice of Privacy Practices upon request.

Signature: ____________________________________________

Date: ____________/____________/____________

Relationship to patient (if signed by a personal representative of patient): ☐Wife ☐Husband ☐Mother ☐Father ☐Sister ☐Brother ☐Other:________________

I authorize Wicker Park Eye Center, Office of Daniel Tepper MD, to obtain all medical records.

Patient Signature: ____________________________________________________

Date: ____________/____________/____________