New Patient Form

Thank you for providing this information prior to your visit. It will be safely stored on our secure server and will make your experience in the office even more efficient. If you have any questions, please feel free to call the office.

     
   
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  REVIEW OF SYSTEMS    
  Do you currently, or have you ever had any SIGNIFICANT problems in the following areas:
         
  ALLERGIC/IMMUNOLOGIC
BONES/JOINTS/MUSCLES
   
         
  Rheumatoid Arthritis:    
  Muscle Pain:    
  Joint Pain:    
         
  CONSTITUTIONAL      
  Weight Loss/Gain:    
         
  EARS, NOSE MOUTH, THROAT    
  Allergies/Hay fever:     
  Sinus Congestion:    
  Post Nasal Drip:    
  Chronic Cough:    
  Dry Throat/ Mouth:    
         
  ENDOCRINE      
  Thyroid/Other Glands:    
         
  EYES      
  Loss of Vision:    
  Blurred Vision:    
  Distorted Vision/Halos:    
  Loss of Side Vision:    
  Double Vision:    
  Dryness:    
  Mucous Discharge:    
  Redness:    
  Itching:    
  Burning:    
  Foreign Body Sensation:    
  Excess Tearing/Watering:    
  Glare/Light Sensitivity:    
  Eye Pain or Soreness:    
  Chronic Infections:    
  Styes or Chalazion:    
  Flashes/Floaters in Vision:    
         
  GASTROINTESTINAL    
  Diarrhea:    
  Constipation:    
         
  GENITOURINARY      
  Genitals/Kidney/Bladder:    
  INTEGUMENTARY (Skin):    
         
  LYMPHATIC/HEMATOLOGIC    
  Anemia:    
  Bleeding Problems:    
         
  NEUROLOGICAL      
  Headaches:    
  Migraines:    
  Seizures:    
         
  RESPIRATORY      
  Asthma:    
  Chronic Bronchitis:    
  Emphysema:    
         
  VASCULAR/CARDIOVASCULAR    
  Diabetes:    
  Heart Pain:    
  High Blood Pressure:    
  Vascular Disease:    
  PSYCHIATRIC:    
         
         
         
  TOWNE LAKE EYE ASSOCIATES OFFICE POLICIES
1. Payment is due when services are rendered unless other arrangements are made beforehand.
2. Patients are responsible for obtaining all information regarding their insurance.
3. Patients are responsible for any bills not paid by their insurance company after 90 days.
4. If we file insurance, patients authorize insurance benefits to be paid directly to the doctor, and understand
    they are responsible for non-covered services.
5. Patients are asked to pick up spectacle/contact lens orders in a timely manner. Orders will be returned
    after 30 days, unless otherwise advised by the patient.
6. Work with a patient's old frame is performed at the patient's own risk. Older frames may break.
7. Contact lens patients - if you wear contact lenses, it is necessary to have a contact lens evaluation. There
    is an extra fee for this service.
I am the guarantor of this account, and I have read, understand, and agree to these office policies. Further, I acknowledge that I am familiar with Towne Lake Eye Associates Privacy Practices.