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Please print the following form, complete and bring with you for your office visit. |
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Ogallala Eye Care John J. Paloucek, O.D.
Date_________/______/_____
Name___________________________________________________ Nick Name_________________________________
Date of Birth ______/_____/_____ Circle M or F
Single Married Name of Spouse:______________________________Name of Parent______________________________
Social Security #_______-_____-_____ Emai lAddress_______________________________________________________
Phone Number (____) _______-_________ Cell Number (____)_______-_______ Work Number (____)_____-_______
Mailing Address______________________________________________City_____________________________________
State_____________________Zip Code________________________
Occupation__________________________________________Employer_________________________________________
Name/Address of Close Relative (Other than spouse)
____________________________________________________________________________________________________
Do You Have Medicare______________Medicaid_____________Blue Cross__________________Other_______________
We will file your insurance as a courtesy; however, your insurance policy is a contact between you and your insurance company. We are not a party to that contract.
Primary Insurance Card Holder__________________________________________________________________________
Do you have glasses Yes______No______
How do you intend to pay? Cash______Check______MC or Visa______ In consideration of professional services rendered and materials supplied, I understand I am financially responsible for payment in full at the time of dispensing. ___________________________________________________________________________________________________ Name Date Past Personal History Are you a tobacco user? Yes_____ No_____ Current Medications___________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Allergies to Medications________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Allergies_____________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Describe all serious illnesses, injuries and surgeries_________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Primary Care Physician Information Name______________________________________________________Address__________________________________ Phone Number______________________________________________ Family History Please note any family member with the following disease or conditions: (M=Mother F=Father S=Sibling GP= Grandparent)
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Review of Systems Check the symptoms and or conditions you currently have or have had in the past. Y=Yes N=No U=Unknown
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