Name: ___________________________________________
Address: _________________________________________
City, State, Zip: ___________________________________
Email Address: ___________________________________
Primary Phone: ____________________________________
Date: ______________________________
Birth Date: _________________________
Occupation: _________________________
Gender: M ______ F _______
Secondary Phone: ____________________
Please describe your reason for visit including any symptoms you are experiencing. Do you have any problems,
questions or concerns with your vision or eye health?
History of Present Illness:
Which eye has the problem?
How long ago did the problem start?
Is the condition
Are there
_____________________________________
List all Oral Medications:
List all Eye Drops and Supplements:
Allergies: (please list) _______________________________________________________________________
Please list anything in your past history, family history or social history which would help us care for you:
Do you currently have any of these symptoms?
ry Eyes
Flashes/Floaters
Mucous/Discharge
Double Vision
Do you have a history of the following eye conditions?
Glaucoma
generation
Vision Therapy/Patching
Other ___________________
Has anyone in your family had any of the above conditions? (please list)
________________________________________________________________________________________
________________________________________________________________________________________
Do you have a history of any of the following conditions?
Vascular Disease
Hypertension
____________________
______________________
Cancer (specify) _______________________________________
___________________
Diabetes (Type 1 or Type 2) ______________________________
___________________
Has anyone in your family had any of the above conditions? (please list)
Are you a current smoker?
Are you pregnant or nursing?
Are you a former smoker?
Do you wear sunglasses?
Are you interested in contact lenses?
Yes
Please read and initial that you understand each of the following:
________ Our Wellness eyeglasses examination is $69. This exam is a required in order to be evaluated for any
other reason or to receive any other service. Extended Health assessment is an additional $30 and is an
uncovered service for preventive care consultation or minor medical eye care recommendations.
________ We recommend that your eyes are dilated for a thorough eye health assessment. The drops that we
use, do not usually cause difficulty with driving vision. The fee is $30.
________ Fees for additional examination, treatment, or services will be charged in cases including, but not
limited to, emergencies, eye infections, foreign body removal, dry eye treatment, referral to specialist,
form completion, retinal photography, contact lens fitting etc. Screening photos are $30 per eye.
________ Contact lens packages which include contact lens fitting and contact lens materials start at $204 and
may be higher depending the complexity and type of fitting required, as determined by the Dr.
________ Cell phones must be turned off (power off) so that our patients, staff and equipment are not disturbed.
Please let our receptionist know if you must step out of our office to use your phone.
________ Our staff and Doctors care about your experience at our office.
If at any time we do not meet your expectations, please bring it to our attention during your visit.
Please answer all of the following:
When was your last eye exam? ______________
Are you a previous patient of ours?
Year?_____
How did you hear about our office?________________________________________________________________
Year of last medical exam to check cholesterol and diabetes?_______ Doctor?__________________
Blood Relative with Glaucoma? Yes / No Who?________________________
How will you make full payment for today’s fees?_________________
To use an accepted insurance, you must give us your valid insurance card and a picture I.D. prior to examination
Please sign that you have read and understand all of the above .__________________________Date:___/___/____
THANK YOU for trusting us with your Vision and Eye Care
Maryland Eye Care Associates
HIPPA Privacy Acknowledgement of Receipt of
Notice of Privacy Practices
I, ___________________________(Print full legal name here) (the”patient” or “patient legal representative”) have
been presented with the Notice of Privacy, (the “policy”) of: Dr. Thomas Vaxmonsky(the “Provider”), and have
been offered a copy of such policy to keep for my records.
______(Please initial here) I hereby acknowledge that I have been provided with a copy of the Policy.
______(Please initial here) I hereby refuse to acknowledge receipt of the Policy. I understand that even though I may
refuse to sign this acknowledgement, the provider may still provide treatment to me.
_______________________ __________
Signature of Patient
Date
_______________________________________________________________________________________________
OFFICE USE ONLY
I, _______________________(Pleae print full legal name here), acting as ____________________ (Please print relationship
to or official position with provider) For provider attempted to obtain the written acknowledgement of receipt of the policy on
__________-(Please insert ate attempt was made), but acknowledgement could not be obtained because:
_______(Please initial here) Patient or Patient’s legal representative refused to sign.
_______(Please initial) Patient or Patient’s legal representative could not communicate sufficiently to obtain acknowledgement.
_______(Please initial) emergency circumstances prevented securing acknowledgement.
_______(Please initial) Other (please specify) ____________________________________________________________
Provider representative Signature________________________________ Date___________