Patient Intake Form

Sex

Race

Race

Ethnicity

Ethnicity

Preferred Language

Preferred Language

Insurance

PLEASE TELL STAFF IF YOU ARE USING A VISION PLAN - THIS IS VERY IMPORTANT. IF THIS IS NOT INDICATED, YOU MAY BE RESPONSIBLE FOR ALL CHARGES!!

Consent for Dilating Eye Drops

A COMPLETE eye exam includes the use of drops to dilate your pupils. Dilation usually causes blurred vision. Some people find driving very difficult following dilation. We strongly suggest you do not drive until you are comfortable doing so. If you wish, you may return for a second visit at no charge (within 90 days) for dilation. If you choose to drive yourself, you acknowledge that you understand the risks and accept full responsibility for injuries to yourself or others. In addition, we strongly suggest you use sunglasses to reduce your increased sensitivity to light while driving. We will provide shades to you at no charge if requested.

Your signature below indicates that you have been warned of the potential risks that dilating eye drops may have on your ability to drive.

Signature on File

I request that payment of authorized Medicare, Medigap or any other insurance benefits be made either to me or on my behalf to KALIN EYE ASSOCIATES for any services furnished me by its physicians.

It is understood that the responsibility for all charges remains with the patient. Additionally payment is to be made at the time or service for amount not paid by insurance.

I authorize any holder of medical information about me to release to all my insurance companies or to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.

I permit a copy of this authorization to be used in place of the original.

I have received a copy of the notice of privacy practices.

By signing above, I give Dr. Kalin/staff my permission to discuss my care with:

Review of Systems

If ALL NORMAL below,

Eyes

Previous Surgery
Contact Lens
Pain
Double Vision
Glaucoma
Cataracts
Macular Degeneration
Dry Eyes
Flashes
Floaters

Ear, Nose, and Throat

Hard of Hearing
Ringing in Ears
Vertigo

Cardiovascular

Chest Pain
Dizziness
Fainting Spells
Shortness of Breath
Irregular Heart Beat
Difficulty Lying Flat

Respiratory

Cough
Congestion
Wheezing
Asthma

Gastrointestinal

Heartburn
Nausea/Vomiting
Jaundice/Hepatitis

Genito-Urinary

Pain/Difficulty
Blood in Urine
History of Kidney Stones
History of STD's

Psychiatric

Anxiety/Depression
Mood Swings
Difficulty Sleeping

Blood/Lymphnodes

Easy Bruising
Gums Bleed Easily
Prolonged Bleeding
Heavy Aspirin Use

Musculoskeletal

Stiffness
Arthritis
Joint Pain/Swelling

Skin

Rash/Sores
Lesions
Hives/Eczema

Neurological

Seizures
Weakness/Paralysis
Numbness
Tremors
Do you have diabetes?
Family History:

Social History

Smoking status:
Alcohol use:
Drugs:

PATIENT PORTAL: To view a summary of your records, visit Kalineye.com and click on the Patient Portal link on the homepage. You will need to register and enter your information exactly as it is listed with the office. Your SS# is needed. The initial password is Kalineye. Login with your email. It may take up to 72 hours for your information to be posted.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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