7 Lttnw Thank you for choosing our practice for your eyecare needs. Please complete all forms in ink. If you have any

concerns do not hesitate to ask for assistance, we will be happy to help you. If vou are new to our practice,

please share with us your primary reason for choosing Lowcountry Vision Care: Our LCVC Savings Plan Location/convenience Yellow pages ad: Verizon HTC Other Ad or Letter (specify) Personal Referral: (name) Optical shop on site Insurance Participation

P A T I E N T INFORMATION NAME: D O B / / SEX: M / F

FIRST MIDDLE LAST

SOC.SECURITY #: - - ARE YOU A MINOR SINGLE MARRIED DIVORCED STUDENT OTHER_ MAILING ADDRESS:_ CITY SIAIE ZIP. STREET ADDRESS: CITY STATE ZIP HOME PHONE: WORK PH; £ELL_PJ± Preferred contact n

EMERGENCY CONTACT: RELATIONSHIP: PHONE #: Occupation: Employer Name: Work Phone: (Ext) Employer Address, Citv: State Zir£

E-mail Address: PLEASE LIST NAME(S) & AGE(S) OF DEPENDENT CHILDREN

IF PATIENT IS A MINOR CHILD, NAME(S) OF L E G A L GUARDIAN(S):

R e s p o n s i b l e Par ty Name of person responsible for this account:.

Address: City.

.Relationship:

Slate. . Z l J L .

Phone#: .Employer:. City. State:

Insurance Information Primary Insurance Co.\

Name of Policy Holder:.

Insured's DOB: l_

Street Address:

Mailing Address:

.Policy #:

.Relationship to patient:

_Group#:

_Soc. Security # _

C i t £

City.

Home phone:

State; State;

Zip;

Zip; Secondary Insurance Co: Policy #; Group#:

Name of Insured:.

Insured's D O B : _

Street Address:

.Relationship to patient:

_Soc. Security #

Citv:

Home phone:

State; Zip:

Mailing Address:.

Employer Name:.

City; State; Zip:

Address: / certify that the insurance information on this form is accurate. I understand J am financially responsible for copays, deductibles &

non-covered services by my insurance company(s) I understand that you may bill me if my insurance company takes longer than 90 days to

make it's payment decision. If my insurance company does subsequently pay you, you will refund to me any portion that is due to me If my

insurance company denies payment, I agree to be personally responsible for payment. I authorize the doctor to release any information

necessary to secure payment of benefits and use of this signature for all insurance claims unless revoked in writing.

Signature Dote / /

Current Visual Function:

If you are here due to a vision or eye health problem, please describe your concerns or symptoms:

Do you currently wear: Glasses Contacts Both Sunglasses Safety Frames 1f you wear prescription glasses or contacts, when are they used?: All the time Distance only Reading/near work only Safety/sports only Other I f you do not wear contact lenses, are you interested in learning if they would be right for you? Yes No

What is your daily computer use? None Less than 1 Hr 1-3 Hours Over 3 Hours How much time do you spend reading/studying daily? None Less than 1 Hr 1-3 Hours Over 3 Hours How much time is spent crafting/close work daily? None Less than 1 Hr 1-3 Hours Over 3 Hours Please mark the following sports/recreations you participate in:

Golf Basketball Hunting Boating/Sailing Swimming

Tennis Softball Fishing Water/snow Skiing Scuba/snorkeling

Walking Soccer Target Shooting Distance Running Other:

Please list your hobbies or interests: Contact Lens Information .-Please indicate the type of contact lenses currently used, check all that apply:

Soft Lenses Gas/Hard Lenses Toric Lenses(astigmatism) Bifocal Lenses Monovision Daily Wear lenses Extended Wear Colored Fashion Lenses

Brand worn i f known: Do you have any complaints with your current lenses? Do you experience Dry eyes? Are your lenses uncomfortable at times? If yes, When? How often do you remove your contacts? Replace them?

General Eye 4 Health History Please rate your current overall physical health: Excellent Good Average Poor

Name & address of Physician:

Office Phone:( ) Date last seen,

Previous eye doctors name & address:

Office Phone:( ) Date last seen:

General Health jjjjtjgg continued Please mark in the appropriate column if you currently have ( Q or previously have hadJPlany of the followin&conditions. In column (F) if a blood family member has or had the condition, please write in their relationship to you; ie mother, brother, etc. A thorough health history contributes to a thorough and comprehensive examination.

Condition C P F Coadsaoa C P P aids/HIV + allergies

amblyopia(lazy eye) i * asthma

arthritis blurring

burning color blindness k

cataracts cataract surgery

cancer • cardiovascular disease • k

diplopia( double vision) dryness

diabetes - T diabetic retinopathy K

ear,nose,throat infections eye infection

1 eye injury epilepsy

emphysema eye surface hemorrhage

eye surgery eyelid infections (stye)

eyelid surgery(eye lift) fainting disorder

i glaucoma K head injury/trauma

j high cholesterol/lipids * high blood pressure a

j itching iritis/u vie tis

I kidney disease * light sensitivity

I liver disease lupus

macular degeneration r migninea/chromc headaches

1 ptosis(one drooping eyelid) pain

redness retinal detachment

strabismus(crossed eyes) r soreness

[strain swelling

' sinus infections shingles

stroke tearing

thyroid disease vertigo(dizzy spells)

vision flashes vision floaters

vision Toss Other: •• - - • t w •

iTiave cornpletedTKs history form to the best of my knowledge.

Signed : Date: / /

Lowcountry Vision Care's Financial Pnlirv

It is the patient's responsibility to provide Lowcountry Vision Care with any current insurance, address and/or referral information and

forms. The patient must pay all co-payments, co-insurances and non-covered services at the time o f their appointment. I f a determination

of benefits cannot be established by the time o f your visit, you are expected to pay in full for services rendered. We wi l l reimburse to you

any payment, subsequent to that date o f service, your insurance company remits to our office. I f eyewear or contact lenses are ordered, a

deposit of 50% is required.We place orders the same day, any order cancellation is subject to a 25% restocking fee The balance is

due in full upon day of dispense unless other arrangements have been made in advance. Goods not picked up within 180 days wi l l be

considered abandoned & donated to the Lions Club with the deposit forfeit. I f your insurance company requires you to obtain a referral

to see a specialist, you must present it on the date and time of your appointment(or earlier). I f your claim is denied because a referral was

required and none was obtained or i f you fail to reply to a coordination of benefits request by your insurance company, you'll be

responsible for all charges incurred for that date(s) o f service. I f your insurance carrier has not reached a decision within 90 days o f

bi l l ing, payment wil l be due in full from the patient.By signing this financial agreement, the patient authorizes Lowcountry Vision Care

to furnish information to insurance carriers and other doctors concerning his/her treatment.They may also obtain pre-certifications and

prior authorizations on the patient's behalf. Lowcountry Vision Care is authorized to receive payments for services rendered on behalf of

the patient and/or their dependents.This authorization remains on file for all future treatments unless revoked by the patient in wri t ing.

You may review or ask to receive a paper copy of the complete Notice of Privacy Practices at any time. You may make the request over

the phone or in person at the reception desk. The Health Insurance Portability & Accountability Act of 1996(HIPAA) is a federal

program that requires that all medical records & other individually identifiable health information used or disclosed by us in any form,

whether electronically, on paper, or orally, are kept properly confidential. This act gives you, the patient, significant new rights to

understand & control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health

information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health

information & how we may use & disclose your information. We may use and disclose your medical record only for any of the fol lowing

purposes: *Treatment-providing, coordinating or managing health care & related services by one or more health care providers.

Examples would be providing refraction prescription and/or eye health conditions when patient referral to a specialist is required, when

prescription spectacle or contact lenses are ordered, and when an eye health medicine is prepared for a pharmacist.

*lnsurance Claims- providing information to an insurance company in order to request payment for services and/or treatments rendered

and for durable goods.

We may contact you to provide appointment reminders, test results, information about treatment options or other eyecare benefits &

services that may be of interest to you. This contact may be made via any of the phone numbers or addresses you provide to us.

Disclosure of your medical information for the above stated purpose might be made orally, via fax, e-mail or by mail as we may conside

most effective for providing your eyecare.Any other uses & disclosures wi l l be made only with your written authorization. You may

revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have

already taken actions relying on your authorization.You have the following rights with respect to your protected health information,

which you can exercise by presenting a written request to Lowcountry Vision Care.

*The right to request a restriction on certain uses & disclosures of protected health information, including disclosures to family

members, other relatives, close personal friends or any other person identified by you.

*The right to reasonable requests to receive confidential communications o f protected health information from us by alternative

means or at alternative locations.

*The right to inspect & copy your protected health information.

*The right to receive an accounting o f disclosures of protected health information

Your signature below indicates your acceptance o f the terms of the above HIPAA policy and Financial policy.

NOTICE OF PRIVACY PRACTICE

Signature

Print Name

Pate:

PQB /

/

/

/

Lowcountry Vision Care Universal Medication Form

Name: Signature

Phone • I have no medication allergies

Birth date:

Allergic to /describe reaction Allergic to / describe reaction

List all prescription medications including eye drops & over the counter (non-prescription) Medications, vitamins & herbal supplements-examples: Ginseng, St Johns Wort, aspirin, Tylenol

Todays Date Medicine/dosage Time taken Date Stopped

Reason for taking and Prescribing doctors name