Returning Patient Information Form

Office Hours

Monday 8:00am to 6:00pm
Tuesday 10:00am to 7:00pm
Wednesday 8:00am to 3:00pm
Thursday 10:00am to 7:00pm
Friday 8:00am to 3:00pm
Saturday 8:00am to 12:00pm

3027 English Rows Ave. Suite 209

Naperville, IL 60564

PHONE: 630.922.2661
EMAIL: contactus@englishrow...

Please join us in the effort to reduce the unnecessary waste of paper by filling out these history forms online. Every time this online form is used, it reduces paper waste by approximately 8 to 10 sheets of paper. Also, please read and review the Online HIPAA Privacy Policy, available on our Forms page. You will be required to acknowledge that you have reviewed the HIPAA Privacy Policy before your information can be submitted on the last page of this questionnaire.

Thank you for your efforts.

Filling out the following form now will help make your visit more punctual and thorough. Required areas to be completed are annotated with a red asterisk *

"*" indicates required fields

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Personal Information

Name*

First Last

Please provide us with your full name.

Date of Birth*

MM slash DD slash YYYY

Please enter your date of birth

SS#: last four digits*

Please provide the last four digits of your Social Security Number

Marital Status*

Single

Married

Divorced

Widowed

Separated

Partner

Please indicate your marital status

Sex*

Male

Female

Please indicate your sex type.

Home Address*

Street Address Address Line 2 City State ZIP Code

Please provide your home address

Email*

Enter Email Confirm Email

We only utilize client email information for internal communications to patients. Your information is never shared.

Home Phone*

Please provide your home or cell phone number

Cell Phone

Please provide your cell/mobile phone number

Work Phone

Please provide your work phone

Texting

Allowed

Would you like to receive text you reminders?

Employer / Student Information

Employment Information*

Employed Full-Time

Employed Part-Time

Self-employed

Retired

Student - FullTime

Student - Part Time

Unemployed

Please indicate your employment or student status.

Employer / School Attending

Please provide your employer name or the name of the school that you are currently attending.

Occupation / Grade Attending

Please provide your occupation title or grade level

Insurance Information

Do you have:*

Medical Insurance

Vision Insurance

Both Medical & Vision Insurance

No Insurance

Please provide your insurance status for us.

Medical Insurance Information

Medical Insurance Company (if applicable)

Type of Insurance Policy*

HMO

PPO

Other

Please provide your insurance status for us.

Policy #

Group #

Medicare #

Vision Insurance Information

Vision Insurance Company (if applicable)

Policy#

Vision Group#

Policy Holder Information

Policy Holder Name

Policy Holder's Date Of Birth

MM slash DD slash YYYY

Policy Holder SS# (last four)

Relationship to Patient*

Policy Holder's Employer

Patient Eye History

Have you had any changes or problems since your last eye exam?*

Yes

If yes, please explain:*

General Health

Your Primary Care Physician:

Phone

Date of Last Medical Exam:

MM slash DD slash YYYY

Height*

Weight*

Have you had any medical changes since your last exam?*

Yes

If yes, please explain:*

Are you taking any medications? If yes, please enter medications and what you use them for*

Yes

Medication Information

Pharmacy Information

Please provide us with your pharmacy name, location, and phone number in the event that we need to contact them regard any prescriptions that need to be ordered on your behalf.

Pharmacy Name

Pharmacy Location

Pharmacy Phone

Allergies

Please list any allergies that you may have

Medication Allergies:

Contact Lenses / Glasses

Are you currently having any problems with your current contacts or eyeglasses?

Meaningful Use

Meaningful Use is a government program to ensure that healthcare professionals are utilizing their Electronic Medical Records system efficiently to improve healthcare quality and patient safety. English Rows Eye Care understands that this is very personal and sensitive information. We want to ensure you that this information will only be used as part of the Meaningful Use objectives.

Preferred Language:*

English

Spanish

Other

Race:*

Ethnicity*

Preferred Communication Methods:*

Postal Mail

Telephone

Authorization

I have reviewed the information on this form and it is accurate to the best of my knowledge. I understand that this information will be used by the Doctor to help determine appropriate treatment. If there is any change in my medical status, I will inform the Doctor.
I authorize my insurance company to pay English Rows Eye Care all insurance benefits otherwise payable to me for services and/or materials.
I understand that a quote of eligibility and benefits from my insurance company is not a guarantee of payment. All benefits are subject to eligibility, medical necessity and the terms, conditions, limitations and exclusions of my health benefit plan at the time services are rendered and that I am financially responsible for all co-pays, co-insurance and non-covered charges.
I authorize the use of this signature on all insurance submissions.
I authorize English Rows Eye Care to release all information necessary to secure the payment of benefits.
I acknowledge that I was offered/provided a copy of English Rows Eye Care’s Notice of Privacy Practices.

HIPAA Acknowledgement Date:*

MM slash DD slash YYYY

HIPAA Acknowledgement Typed Name*

First Last