Mr. Mrs. Miss Ms Dr. Pastor Captain
______________________________ ___ _________________________
First Name MI Last Name
Street Address: _________________________________________________________
City _________________________ State ______________ Zip ________________
Social Security # ____-____-_____ Date of Birth: ___________________ Male Female
Home # _________________ Work # ___________________ Mobile # __________________
Email: __________________________________ Preferred Contact Home Work Mobile
I authorize Georgia Eye Partners to communicate my protected health information to me with a
detailed message via the following methods: Voicemail (home or mobile #) E-mail
I do not authorize Georgia Eye Partners to leave detailed messages on voicemial or email
I agree to receive text messages to the above mentioned mobile number reminding me about my
upcoming appointments. I understand that SMS reminders are optional and that message & data
rates may apply. Yes No
Emergency Contact Information
_________________________ ____________________ Relationship: ____________________
First Name Last Name
Home # _________________ Work # ___________________ Mobile # __________________
Occupation ____________________________
Race ________________ Ethnicity __________________ Language __________________
Referring Physician: _________________________________________________
Eye Doctor: _______________________________________________________
Primary Care Physician: ______________________________________________
Designated HIPAA Release & Communication
At my request, I authorize Georgia Eye Partners to disclose my protected health information to:
Name: ____________________________ Relationship ________________ Phone ______________
Name: ____________________________ Relationship ________________ Phone ______________
Medical Insurance Information
Insured Party Name: ___________________ _________________________ Same as Patient
First Last
Street Address: _____________________________________________________________________
City _________________________ State ______________ Zip ________________
Date of Birth: _______________ Social Security #: ____-____-_____ Home #: ______________
Patient Relationship To Insured: Self Child Spouse Other Gender: Male Female
Insurance Company Name: ________________________________
Insurance Plan Name: ___________________________ Type: ____________________
Insurance ID Number: __________________________ Policy # ___________________
Notice of Privacy Practices
I, _________ hereby affirm that a copy of the
Notice of Privacy Practices
Georgia Eye Partners has been presented to me and a copy is available upon request. Under
federal law 104-191, known as HIPAA, I am entitled to receive a copy of this
from my
healthcare provider.
My signature below also affirms the information I have provided is factual and accurate. My
signature also signifies that I have been presented with a copy of the
Notice of Privacy Practices
does not legally bind or obligate me in any way
I voluntarily consent to evaluation and treatment from the physicians and staff at GEP. I am aware
that the practice of medicine is not an exact science and no guarantees have been made regarding
the results of treatment or examinations by GEP. I consent to the use and disclosure of protected
health information about me for treatment, payment and operations.
_______________________________________________ ___________________________
Signature of Patient or Legal Guardian Date Name of Patient or Legal Guardian
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Patient Health History Questionnaire
Reason for visit:
Do you take any prescribed or over the counter eye drops? Yes No
Please list all eye drops: _____________________________________________________________________
Have you received the flu vaccine within the last 12 months? Yes No Pneumococcal Vaccine? Yes No
Do you wear glasses/contact lenses or both? Yes No Contacts Soft Hard
Do you have or have been previously treated for any of the following health conditions:
Cataracts No Yes (please explain) _______________________________________________
Cornea Disease No Yes (please explain) _______________________________________________
Crossed/lazy Eye No Yes (please explain) _______________________________________________
Diabetic Eye Disease No Yes (please explain) _______________________________________________
Dry Eye No Yes (please explain) _______________________________________________
Eye Injury No Yes (please explain) _______________________________________________
Glaucoma No Yes (please explain) _______________________________________________
Macular Degeneration No Yes (please explain) _______________________________________________
Retinal Tear No Yes (please explain) _______________________________________________
Retinal Detachment No Yes (please explain) _______________________________________________
Abnormal Bleeding No Yes (please explain) _______________________________________________
Arthirits No Yes (please explain) _______________________________________________
Cancer No Yes (please explain) _______________________________________________
Diabetes No Yes Controlled? No Yes by: Diet Pills Insulin
Gastrointestinal No Yes (please explain) _______________________________________________
HIV/AIDS No Yes (please explain) _______________________________________________
High Blood Pressure No Yes (please explain) _______________________________________________
Heart Attack No Yes (please explain) _______________________________________________
Heart Disease No Yes (please explain) _______________________________________________
Kidney Disease No Yes (please explain) _______________________________________________
Liver Disease No Yes (please explain) _______________________________________________
Stroke No Yes (please explain) _______________________________________________
Other No Yes (please explain) _______________________________________________
Are you pregnant or breastfeeding? No Yes Due Date _______________________________________
Have you ever had surgery on your eye(s)? No Yes, please list all surgeries with dates & doctor below:
Todays Date _____________________________
Patient Name _____________________________
Date of Birth _____________________________
Referring Doctor __________________________
Please list all other surgeries with dates and surgeon name: None
List all other medications including any over-the-counterand prescription. Include dosage and frequency:
________________________________________ ___________________________________
________________________________________ ___________________________________
________________________________________ ___________________________________
Are you allergic to any medications? No Yes If Yes, please list all allergies and reactions:
Has anyone in your family has any of the following? If yes, please list relationship:
Cataracts No Yes Who? _______________________________________________
Cornea Disease No Yes Who? _______________________________________________
Crossed/lazy Eye No Yes Who? _______________________________________________
Glaucoma No Yes Who? _______________________________________________
Macular Degeneration No Yes Who? _______________________________________________
Retinal Tear No Yes Who? _______________________________________________
Retinal Detachment No Yes Who? _______________________________________________
Diabetes No Yes Who? _______________________________________________
Other No Yes Who? _______________________________________________
Social History
Do you smoke? Never Yes, ____ pack/day Former Smoker, quit date ____________
Alcohol Use? No Yes
If Yes 3 or less drinks per week 4 or more drinks per week
Review of Systems Are you currently experiencing any problems?
Constitution (weight gain, loss of appetite, other) No Yes _________________________________
Cardiovascular (chest pain, irregular rhythm, other) No Yes _________________________________
Ear, Nose, Mouth (dryness, sore throat, runny nose, earache) No Yes _________________________________
Respiratory (shortness of breath, wheezing, cough, other) No Yes _________________________________
Gastrointestinal (constipation, diarrhea, acid reflux, other) No Yes _________________________________
Genitourinary (painful urination, incontinence, other) No Yes _________________________________
Musculoskeletal (joint pain/swelling, muscle ache) No Yes _________________________________
Integumentary (skin rash, itching, other) No Yes _________________________________
Neurological (headache, dizziness, other) No Yes _________________________________
Psychiatric (anxiety, depression, other) No Yes _________________________________
Endocrine (frequent urination, frequent thirst, other) No Yes _________________________________
Hematologic/Lymphatic (anemia, excessive bleeding) No Yes _________________________________
Allergic/Immunologic (hay fever, itchy eyes, other) No Yes _________________________________
Height: ____________ Weight ___________
Updated 6.6.20
Patient Financial Responsibility Agreement
In order for us to provide our patients with quality medical care, we must receive payment for our services.
This document explains the patient’s obligations in regards to financial responsbility for services rendored.
In exchange for services rendered, each patient or patient’s guarantor agrees to:
Authorize payment of surgical and medical benefits to Georgia Eye Partners (GEP), which would
otherwise be payable to you. If covered by Medicare or Medicaid, I certify that the information
provided by me in applying for payment and titles V, XVII, and/or XIX of the Social Security Act is
Pay all non-covered charges (including refraction), co-pays, co-insurance, deductible, and out-of-
network charges at the time of service.
o Refraction Fee: $40.00.
o Cancellation Fee: $40.00 Applied for failure to provide a 24 hour cancellation notice
o Contact Lens Fitting Fee: This fee varies depending on the type of contact lens you request or
the type of lenses necessary to provide you the best possible vision. The fee is collected in
addition to the fee for an eye examination.
Provide a copy of your most recent insurance card, other proof of insurance and/or register with the
receptionist at the time of EACH visit. If you do not provide us with valid insurance information at the
time of EACH visit, and your insurance company subsequently denies our claim, you will be responsible
for any and all charges.
Obtain any authorization or referral required by your insurance plan and/or from your Primary Care
Physician prior to each appointment. If you do not receive the required authorization and insurance
does not pay for services rendered, you will be responsible for any and all charges. Additionally, we
may need to reschedule your visit if you do not have your authorization or referral.
In the event we must refer the patient’s account to a collection agency or attorney for collection of an amount
90 days or older, the patient and/or guarantor agrees to pay our collection fee, including any accrued interest
and all applicable bank fees incurred for a returned check.
As the patient or guarantor of a patient, I agree that in consideration of the services rendered by GEP, I am
individually obligated to pay for all services in accordance with the regular rates, terms and conditions of GEP.
As a courtesy to our self-pay patients seeking routine eye care, GEP will provide a reduced charge if services
are paid in full at time of rendering. Once you accept the discount, we will not be responsible for filing claims
to any insurance company nor will we accept payment from any insurance company. In the event we receive
an insurance payment under these circumstances, we will refund the money to the insurance company.
I have read this form and have had the opportunity to ask questions and my questions have been answered.
By my signature, I represent that I have voluntarily read, understand and agree to be bound by the above
_____________________________________________ ________________________________
Patient or Guarantor - Signature Date
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