Welcome Package Step 1 of 6 - Contact Information0%Patient ID:We would like to welcome you to our practice and ask that you kindly complete all information listed. Please bring the information with you to your appointment so we may include it in your file.Office Location*DoverSeafordMillvilleName* First Last Date of Birth* Date Format: MM slash DD slash YYYY Age*Social Security NumberMarital StatusAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender:*MaleFemaleHome Phone*Work Phone*Cell Phone*Email* OccupationEmployerEmployer Phone*Family Doctor / PCPFamily Doctor / PCP Phone*Emergency ContactEmergency Contact Phone*Upon my request, I hereby authorize my medical records and/or personal information to be released to the following family members/doctor offices (this includes requests for medication refills, office notes, etc.): Recipients:Name of Recipient First Last RelationshipPhone NumberName of Recipient First Last RelationshipPhone NumberDemographicPrimary Language*EnglishFrenchSpanishEthnicity*Latino or HispanicNot Latino or HispanicRace*WhiteBlack or African AmericanNative Hawaiian or Other Pacific IslandAmerican Indian or Alaska NativeAsianMedical HistoryPlease choose YES or NO if you ever been diagnosed with any of the following:Cataracts*YesNoGlaucoma*YesNoRetinal Detachment*YesNoMacular Degeneration*YesNoAny other eye diseases or conditions:Have you ever had any injuries or surgeries to your eyes (including laser)?*YesNoIf yes, please explain.Do you currently have any of the following problems? Please choose YES or NO. If Yes, please explain.Chronic fever, fatigue, unexpected weight gain/loss*YesNoIf yes, please explain.Ear/nose/throat problems*(e.g. hearing loss, sinus infection, sore throat)YesNoIf yes, please explain.Heart problems*YesNo(e.g. chest pain, irregular heartbeat, high blood pressure)If yes, please explain.Respiratory problems*(e.g. shortness of breath, wheezing, coughing, asthma)YesNoIf yes, please explain.Gastrointestinal problems*(e.g. heartburn, abdominal pain, diarrhea, vomiting)YesNoIf yes, please explain.Urinary problems*(e.g. pain or discomfort, blood in urine, difficulty voiding)YesNoIf yes, please explain.Skin problems*(e.g. rashes, excessive dryness)YesNoIf yes, please explain.Musculoskeletal problems*(e.g. muscle aches, joint pain, swollen joints)YesNoIf yes, please explain.Neurological problems*(e.g. numbness, weakness, headache)YesNoIf yes, please explain.Psychiatric problems*(e.g. depression, anxiety)YesNoIf yes, please explain.Endocrine problems*(e.g. diabetes, thyroid disease)YesNoIf yes, please explain.Blood problems*(e.g. anemia, bleeding tendency)YesNoIf yes, please explain.Have you ever been exposed to Hepatitis B or Hepatitis C?*YesNoIf yes, please explain.Have you ever tested positive for the HIV Virus?*YesNoIf yes, please explain.Smoking:Do you or have you ever smoked?*YesNoIf yes, how many pack per day?How long ago did you quit smoking?Primary Pharmacy (Where would you like your prescriptions sent to):Pharmacy NameLocationPhoneSecondary PharmacyPharmacy NameLocationPhonePlease list any ALLERGIES and REACTIONS:AllergyReaction Please list all medications, including over the counter and eye drops that you are currently taking:Medication NameAmount/Dosage Medical InsurancePlease make every effort to fill in the information on the pages requesting your insurance information. Incomplete information may prevent your visit from being billed to the appropriate insurance plan.Primary Medical Insurance:CompanyPhonePolicy #Group #Subscriber First Last Subscriber's Date of Birth Date Format: MM slash DD slash YYYY Subscriber's Social Security NumberRelationship to PatientSelfSpouseParentSubscriber's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Specialist Copay:Secondary Medical Insurance:CompanyPhonePolicy #Group #Subscriber First Last Subscriber's Date of Birth Date Format: MM slash DD slash YYYY Subscriber's Social Security NumberRelationship to PatientSelfSpouseParentSubscriber's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Specialist Copay:Tertiary Medical Insurance:CompanyPhonePolicy #Group #Subscriber First Last Subscriber's Date of Birth Date Format: MM slash DD slash YYYY Subscriber's Social Security NumberRelationship to PatientSelfSpouseParentSubscriber's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Specialist Copay:Is this visit the result of an accident?YesNoWhat type of accident?AutoEmploymentDate of Accident Date Format: MM slash DD slash YYYY Insurance Information:CAPTCHANameThis field is for validation purposes and should be left unchanged.Copyright © 2017 Eye Specialists of Delaware. 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