Online Patient History Form Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Please provide a telephone number, with area code, so we can contact you.Home PhoneCell PhoneEmail AddressPlease provide us your email address.Insurance InformationName of SubscriberDate of Birth* MM slash DD slash YYYY Social Security NumberInsurance Company NameInsurance Company ID NoEye HistoryDo you have or experianced any of the following Double Vision Dryness Burning Glare Headaches Redness Flashing Lights Itching Floaters Other OtherFamily HistoryPlease check if any member of family has any conditions below Glaucoma Cataracts Macular Degeneration Retinal Detechment Other OtherMedical ConditionsDo you have any of the following High Blood Pressure Diabetes High Cholesterol Hyer/Hypo Thyroid Other OtherList any medications you currently take List any allergies you may have Assignment and ReleaseI certify that I, and/or my dependents have insurance coverage with ___________ and assign directly to Dr. Shrayman all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submission. SignatureDate MM slash DD slash YYYY Notice of Privacy PracticesDr. Shrayman is required by law to protect certain aspect of your health care information and to provide you with a Notice of Privacy Practices. The notice describes our privacy practices, your legal rights and lets you know how Dr. Shrayman is permitted to: Use and disclose PHI about you How you can access and copy information How you may request amendment of that information How you may request restrictions on your use and disclosure of your protected health information The notice is available for you at the front desk. Please sign that you have received and reviewed its contents.SignatureDate MM slash DD slash YYYY Consent for DilationA comprehensive eye examination includes pupillary dilation in order to better view the back of the eye (the retina). Dilation requires instilling drops into the eyes which will dilate the pupils, causing sensitivity to light and near vision blur that will last for several hours. You may do this today, reschedule for a time that is more convenient for you, or decline the procedure done. There is no extra charge for this procedure. I have been informed of the risks/benefits of dilation and* DO want a dilated eye exam today. DO NOT want a dilated eye exam today. SignatureDate MM slash DD slash YYYY Fast, easy, and comfortable May alleviate the need for dilation Provides a permanent record for annual review This doctor recommends performing an optomap exam on all patients. An optomap image captures up to 82% of your retina in a single image. These images help in the early detection of many diseases, including macular degeneration, glaucoma, and retinal detachments. These problems can threaten vision without warning or symptoms. Serious health problems unrelated to the eye such as diabetes, hypertension, heart disease, some cancers, and auto-immune disorders, may also be detected with an optomap image.The cost of the optomap is only $49. I understand that I will be receiving an optomap as part of my eye exam today and do not have any questions. SignatureDate MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ Print this form
