Eye Associates of Tallahassee

Is now seeing Patients at Doctors’ Memorial Hospital 333 Byron Butler Parkway, Perry, FL 32347

*Specialty Clinic – to the right of hospital welcome desk

Eye Associates of Tallahassee, P.A. Ophthalmology, Optometry, and Ophthalmic Surgery

2020 Fleischmann Road Tallahassee, Florida 32308 Tel: (850) 878-6161 ■ Fax: (850) 656-0200 www.EyeAssociatesofTallahassee.com

“ALL YOU NEED TO SEE”

Welcome to Eye Associates of Tallahassee!

Francis C. Skilling, Jr., M.D. Tony A. Weaver, M.D. Kenneth P. Kato, M.D.

Jerry G. Ford, M.D. Viet N. Bui, M.D.

Fang Sarah Ko, M.D. Deanna M. Louie, M.D.

Sterling L. Cannon, M.D.

Diplomates, American Board of Ophthalmology

Fellows, American Academy of Ophthalmology

Joshua M. Trafton, O.D.

Elizabeth J. Strickland, O.D. (Perry) Board Certified Optometrist

Vicky O'Sullivan, M.S.W. Administrator

Thank you for choosing our office to give you the best quality services for your eye care needs. If you are a new patient, please review, complete and mail or fax your new patient paperwork to us at least two days prior to your office visit. You may also visit www.EyeAssociatesofTallahassee.com and complete the process using our patient portal, preferred method. Having this completed beforehand will allow us to expedite your check in more efficiently.

Listed below are helpful reminders for your appointment on:

• Please bring your photo ID & Insurance card(s) in order to prevent identity theft. • We kindly accept cash, checks, and credit cards for co-pays or deductible payments. • Please bring a list of medications you are currently taking. This will be reviewed and updated during your

visit. • Please wear your glasses and bring your contact lens case to your appointment. For best measurements,

Cataract and iLasik evaluations should be out of soft & hard contacts for 3 weeks prior to your consult. • When you arrive in our office, please sign in on the tablets on the wall with your home or cell phone number

followed by your first and last name. Once you have completed this you can take a seat in the waiting room until a patient services representative summons you to the front desk. You will see your name highlighted on the screen and you will hear a ding reading off the last 4 digits of your phone number followed by what check in station you need to report to, in order to complete your check in process.

Please contact us at (850) 878-6161 for additional questions or assistance. We look forward to helping you and your family with all your eye care needs.

Eye Associates of Tallahassee

2020 Fleischmann Road, Tallahassee, FL 32308

*Across the street from Holy Comforter Episcopal School

and next door to Southeastern Dermatology

Eye Associates of Tallahassee Hospital

Doctors’ Memorial

Mar. 2018pg. 1 of 3

Eye Associates of Tallahassee, P.A. Ophthalmology, Optometry, and Ophthalmic Surgery

2020 Fleischmann Road Tallahassee, Florida 32308 Tel: (850) 878-6161 ■ Fax: (850) 656-0200 www.EyeAssociatesofTallahassee.com

“ALL YOU NEED TO SEE”

Emergency Contact

Name Home # Cell or Work #

Relationship

Complete if Under 18 Years Old and/or Student

Name of Parent/Guardian D.O.B. / /

Home Phone # Cell or Wk. #

Email Relationship

Insurance Information

o Capital Health Plan o Capital Health Plan Medicare

o Medicare o Blue Cross Blue Shield

o United Health Care o Aetna

o Medicaid (authorization required) o VA Medical (authorization required)

o Division of Blind Services (authorization required) o Other:

Group Number Plan Name Effective Date / /

Member Name Member ID

Secondary Insurance

Group Number Plan Name Effective Date / /

Member Name Member ID

PATIENT’S NAME:

CELL PHONE # DAY PHONE # HOME PHONE #

Which of the following contact number(s) may we leave a message on: cell ☐ day ☐ home ☐

ADDRESS:

CITY: STATE: ZIP:

D.O.B.: / / Employed By:

EMAIL: NAME OF PHARMACY:

Who can we thank for your referral?

☐ Website / Internet ☐ Facebook/Twitter/Instagram ☐ TV/ Radio ☐ Newspaper/Magazine ☐ Insurance Company: ☐ Friend or Family Member: ☐ Eye Associates Employee: ☐ Physician: ☐ On-Call:

☐ Other:

Mar. 2018pg. 2 of 3

Family Physician Phone Date of Last Visit

Eye Care Physician Phone Date of Last Visit

Do you have OR have you ever been told you have the following?

Yes No Diabetes (Controlled by Insulin, Pills, Diet) Yes No Frequent Headaches/Migraines

Yes No Heart Disease Yes No Blurry/Distorted/Double Vision

Yes No High Blood Pressure Yes No Claustrophobia/Anxiety

Yes No Chest Pain / Angina Yes No Sleep Apnea

Yes No Irregular Heart Rate Yes No Problems Lying Flat

Yes No Pacemaker Serial # Yes No Stomach Ulcer/Hernia/Reflux

Yes No Neurological Disorders Yes No Take A Medication for BPH, (i.e., Flomax)

Yes No Kidney Failure / Dialysis Yes No Take Blood Thinners, i.e. Coumadin or Aspirin

Yes No Thyroid Disease Yes No Wear A Hearing Aid Lt / Rt / Both

Yes No Hepatitis/AIDS/HIV/Tuberculosis Yes No Problems with Anesthesia

Yes No Arthritis (type)

Yes No Cancer (type) Yes No Smoke/Tobacco (How Much)

Yes No Dementia/Alzheimer's Yes No Drink Alcohol (How Much)

Yes No Immune Disorder Yes No Caffeine (How Much)

Yes No Lung Disease (COPD/Asthma) Yes No Recreational Drugs

Family History

Has anyone in your immediate family (parents, grandparents, brothers, or sisters) had problems with any of the following? List member(s)

Yes No Cataracts Yes No Eye Muscle Problem

Yes No Cornea Problems Yes No Glaucoma

Yes No Diabetic Eye Disease Yes No Retina Problem

The information that I have given concerning my medical history is true and correct to the best of my knowledge. For my safety, I will obey all instructions and have responsible

transportation and home care available.

Printed Name of Patient Date

Signature of Patient or Authorized Representative Date

Rev. by ______ Date ______

Mar. 2018pg. 3 of 3

SURGICAL HISTORY

Please list all past surgeries including eye surgeries.

Surgery Date

MEDICATION RECONCILIATION

Please list all medications you are currently taking including over-the-counter, herbal medicine, home remedies, eye drops, and vitamins (use back of page if necessary).

MEDICATION NAME (write legibly)

DOSE / FREQUENCY / ROUTE (i.e., mg, mcg by mouth once a day)

RX IS USED TO TREAT

(i.e., Prozac – anxiety)

ALLERGIES

ALLERGIES TYPE OF REACTION

Printed Name: Date / /

Patient’s Signature: Date / /

Reviewed By: Date / /

INTERNAL USE ONLY: Employee Signature Date Entered