New Patient Form – Drs. Logan and Bailey

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Patient Intake Form

This form is for new patient information and does not schedule an appointment. To schedule an appointment, visit our website or call 765.966.2661.
Patient Legal Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Today's Date*

MonthDayYear
Date
Patient Information
Preferred Name:

First NameMiddle NameLast Name
Gender*
Age*
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityCounty

Postal Code
E-mail*
example@example.com
Employer/Occupation
SSN (if insurance requires)
How did you hear about us?
Responsible Party

If patient is a minor.
Parent'Guardian Full Name:

First NameMiddle NameLast Name
Relationship to Patient
Date of Birth

DayMonthYear
Primary Phone Number

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityCounty

Postal Code
E-mail
example@example.com
Vision Insurance
Insurance Carrier
Policy Number
Policy Number
Secondary (if applicable)
Medical Insurance
Insurance Carrier
Policy Number
Group Number
Secondary (if applicable)
Policy Holder Information

(if different from patient)
Name (as shown on card)
Date of Birth*

DayMonthYear
Address:*

Street Address

Street Address Line 2

CityCounty

Postal Code
Primary Phone Number*

Area CodePhone Number
SSN (if insurance requires)
Primary Care Information
Physician Name
Phone Number

Area CodePhone Number
Pharmacy Information
Pharmacy Name
City & Zip Code (separate with comma)
ex: Happytown, 12345
HIPAA Privacy Notice
This HIPAA Policy was available to read during my office visit. Patient initials here.*
We do not share your personal health information (PHI) with anyone without your authorization. In case of emergency, please provide information for one individual with whom we may share your medical records.

Authorized IndividualPatient initials here.*
Phone Number Area Code* Phone Number*
Statement of Financial Responsibility
In order for my eyecare provider to service my account, or to collect any amounts I may owe, I agree that I may be contacted at any number or address I have provided above or during a previous encounter. I understand that my eye exam and any optional contact lens fitting copayments are due today, and glasses or contact lenses may not be dispensed if those copayments are unpaid. I also understand that fees for services are non-refundable and non-negotiable, and any contact lens prescriptions given are valid for one year per federal law. I furthermore agree to pay any collection expenses incurred to collect any amount I may owe due to non-payment. I understand that I am solely responsible for the cost of all non-covered items, as outlined in detail on my receipt which includes: the specific date of service, description of each procedure/service, and the amount I am responsible for paying out-of-pocket; I certify that I have been informed of all items and cost. I authorize the release of my information for my eyecare provider to file all insurance claims if we are a participating provider for your plan. However, there is no guarantee of benefit information and/or coverage and if my insurance denies payment for any claims submitted, I will be responsible for full payment and can contact my insurance company directly should there be a dispute. My eye care provider can also supply me with an itemized statement which I may submit to my insurance carrier, should I need to submit for reimbursement. I understand that any follow-up appointments related to a contact lens evaluation are included for three months after the initial fitting, and should there be any follow-up appointments required after the three months have passed, I am responsible to pay the professional service fee. Additionally, I know that any optional testing that I have verbally agreed to pay for is my responsibility to do as such on the date of service. Should I receive a medical examination, I understand that my major medical insurance will be billed and I will be responsible for any deductibles, coinsurance, or copayments that may be due.
I have read and understand the Statement of Financial Responsibility. Signature of Patient (or Parent/Guardian)*

Patient Intake & Health Information
Patient Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Date
Name of Family Physician
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Last Physical

MonthDayYear
Date
Height
Current Medications (RX or Over-the-Counter)
List name of medications, including eye drops, vitamins & birth control pills, dosages, and frequency. Please bring a list if necessary.
Allergic to medications? If so, list them here.
Cigarette/Tobacco, Alcohol, or other substance use*
If yes to the above question, please list frequency.
ex: 2-3 times a week/month/year
Patient Eye History
Previous Doctor Name
Date of Last Eye Exam

MonthDayYear
Date
Eye-related surgeries? If so, list them here.
Have you ever been diagnosed, or treated for the following? (check box if yes)

Blurry VisionBurningCataractsCorneal AbrasionsCrossed Eye/Eye TurnDouble VisionEye InfectionsEye InjuryFlash of LightFloaters/SpotsGlaucomaGrittinessHeadachesIritis/UveitisItchinessLazy EyeMacular DegenerationOccasional DrynessRetinal DetachmentSunlight SensitivityTearingTrouble Seeing at NightUncomfortable GlassesOther Eye Disorders
Family Medical/Eye History
Do you have a family medical history of any of the following? (Check all that apply and indicate mother and/or father’s side)
Blindness (Mother)Blindness (Father)Corneal Problems (Mother)Corneal Problems (Father)Cataracts (Mother)Cataracts (Father)
Diabetes (Mother)Diabetes (Father)Glaucoma (Mother)Glaucoma (Father)Heart Disease (Mother)Heart Disease (Father)
Lazy Eye (Mother)Lazy Eye (Father)Macular Degernation (Mother)Macular Degeneration (Father)Retinal Problems (Mother)Retinal Problems (Father)
Patient Medical History
Have you ever been diagnosed, or treated for the following health problems? (check box if yes)

AllergiesFeversArthritisGenitourinaryBlood/LymphHigh Blood PressureBronchitisIntegumentary (skin)CancerKindeyCholesterolMuscle/BoneDiabetesNeurologicalDigestiveRespiratoryEars/Nose/ThroatSinusEndochrineThroat InfectionsEczema/RashesThyroidFatigueWeight Loss/Gain
Other conditions we should know about.
Signature of Patient (or Parent/Guardian)*

Clear
If you have not booked your appointment, please do so by calling our office at 765.966.2661 or visiting our website and clicking Book an Appointment.

If you have scheduled your appointment, please be sure to bring the following items to your appointment at Drs. Logan and Bailey Vision Care:
- Social Security Number
- Insurance Card(s)
- List of any medications you currently take (if requested by your eye care provider)
- Driver's License
Should be Empty:

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