Dr. Mrs. Ms. Mr. First Name ________________________ M.I. ____ Last _________________________

Nickname (Preferred name): ______________________

Sex: M F SS#___________________________ Date of Birth _____/_____/_______ Age ______

Marital Status: Married Single Divorced Widowed

Mailing Address _____________________________________Email

City State Zip Code

Home Phone (_____) Mobile Phone (_____)

Employer Work Phone ( )

Emergency Contact: Name Phone Relationship

Pharmacy Name: Location:

Language Preference__________________ Circle Ethnic Background: Hispanic or Non Hispanic

Circle Race: White Black Native Hawaiian Asian American Indian

HOW DID YOU HEAR ABOUT US? (Circle all that apply):

KLBJ 590AM/99.7FM Spirit 105.9FM KFMK Majic 99.5FM KKMJ Other Radio

Television Pandora Spotify Hulu YouTube Facebook

Yelp Google Bing Community Impact Marketing Event Other

Dr. _____________________ Previous Patient Family/Friend ____________________

MEDICAL INSURANCE INFORMATION

If you would like us to file claims with insurance, please fill out the section below. You may be required to obtain a referral (and keep it up to date) from your primary care physician before insurance will pay for an exam with Dr. Restivo, Dr. Shepler, Dr. Wollan or Dr. Osterman. It is the responsibility of the patient to obtain referral authorization before their visit, our office will try to verify a current referral. Per the contract between you and your insurance company, you will be responsible for any charges if a referral cannot be obtained and your insurance company denies payment. Primary Insurance _______________________________________ HMO _____ PPO _____ Other _____

Subscriber’s Name ______________________________________ Subscriber’s DOB ____/____/_____

Insurance ID# Group#

Secondary Insurance _____________________________________ HMO _____ PPO _____ Other _____

Subscriber’s Name ______________________________________ Subscriber’s DOB ____/____/_____

Insurance ID# Group#

VISION PLAN

(We will not bill your vision plan because we are not providers for those plans.)

MEDICAL HISTORY

Primary Care Physician: Dr. _______________________________

Current Optometrist: Dr. _________________________________ Last Exam __________

History and Intake Form

Past Medical History: (please circle all that apply)

Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease

Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism

Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke None

Other _______________________________________________________________________________ Past Surgical History: (please circle all that apply) L= Left R = Right Appendectomy Hip Replacement L R Prostate Biopsy Bladder Removed Knee Replacement L R Prostate Cancer Breast Biopsy L R Kidney Biopsy L R TURP Lumpectomy (Breast) L R Kidney Stone Removed Rectum: APR Mastectomy (Breast) L R Kidney Transplant L R Rectum: LAR Colectomy: Resection Kidney Removed L R Basal Cell Cancer Colectomy: Diverticulitis Liver Removed Melanoma Surgery Colectomy: IBD Liver Transplant Skin Biopsy Colostomy Liver Shunt Squamous Cell Carcinoma Gallbladder Removed Ovaries Removed: Endometriosis Spleen Removed Biological Valve Replacement Ovaries Removed: Cancer Testicles Removed Coronary Artery Bypass Ovaries Removed: Cyst Hysterectomy: Fibroids Heart Transplant Ovaries: Tubal Ligation Hysterectomy: Uterine cancer Mechanical valve replacement Pancreas Removed Hysterectomy: Cervical cancer PTCA Other _________________________________________________________________________

Ocular History: (please circle all that apply) L = Left Eye R = Right Eye

Other ______________________________________________________________________________ Ocular Surgery: (please circle all that apply) L = Left Eye R = Right Eye

Allergic conjunctivitis L R Dry eyes L R Ophthalmic Migraine L R Blepharitis L R Glasses Pseudoexfoliation L R Cataract L R Glaucoma L R Retinal tear L R Contact lens L R Macular degeneration L R Strabismus L R Corneal dystrophy L R Macular ERM L R PVD L R Diabetic retinopathy, background L R Narrow angles L R Vitrous floaters L R Diabetic retinopathy, proliferative L R Ocular hypertension L R

Blepharoplasty L R LPI L R Trabeculectomy L R Cataract surgery L R LTP L R Tube shunt L R Corneal transplant L R PRK L R Yag capsulotomy L R DSAEK L R Ptosis repair L R RK L R Eye Muscle Surgery L R Punctal plugs L R SLT L R Intravitreal injections L R Strabismus L R Vitrectomy L R LASIK L R Retinal laser L R

HistoryofContactLensUse:NoPreviousHistory______#ofYearsUsed_________

SoftToric_____SoftDailyWear_____SoftOvernightWear______RigidGasPermeable______

HardContacts(PMMA)_____Haveyoutriedmonovisionbefore?Yes/No

Contactbrandifknown:_______________________________Datelastworn_____/_____/_____

Medications: (Please list all current prescribed and over the counter medications) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies: (Please list all allergies and your reaction) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SocialHistory:

(1)Smokingstatus: Currentsmoker Formersmoker Haveneversmoked

Ifcurrentsmoker,_____packs/dayfor_____years.

Ifformersmoker,approximateyearstopped_____

(2)Drink? ____No_____yes(onlysocially_____orrarely_____)

Ifyes,_____drinks/weekfor_____yearsFamily History: (please circle all that apply) M=Mother F=Father B=Brother S=Sister MG=Maternal Grandparent PG=Paternal Grandparent

Blindness M F B S MG PG CVA M F B S MG PG Glaucoma M F B S MG PG Cancer M F B S MG PG Diabetes M F B S MG PG Migraine M F B S MG PG Cataracts M F B S MG PG Heart Disease M F B S MG PG Strabismus M F B S MG PG Retinal Detachment

M F B S MG PG Macular Degeneration

M F B S MG PG

Review of Systems: Are you currently experiencing any of the following? (please check yes or no)

System YES NO Poor vision Eyes Loss of Vision Eyes Eye pain Eyes Tearing Eyes Redness Eyes Jaw pain Eyes Scalp tenderness Eyes Amaurosis fugax Eyes Uncontrolled blood sugar Endocrine Thyroid abnormalities Endocrine Uncontrolled blood pressure Cardiovascular Headache Neurological Paralysis Neurological Allergies Allergic/Immunologic Fever Constitutional Ear ache ENT and mouth Shortness of breath Respiratory Incontinence Genitourinary (G.U.) Joint pains Musculoskeletal Arthritis Musculoskeletal Rash Integumentary Anxiety Psychiatric Depression Psychiatric Insomnia Psychiatric Bleeding Hematologic/Lymphatic Anemia Hematologic/Lymphatic Other Symptoms: _______________________________________________________________ Alerts: Are you currently experiencing any of the following? (please check yes or no)

Alert YES NO Allergy to lidocaine Allergy to adhesive Allergy to Fluorescein Steroid responder

Blood thinners Narrow angles Pseudoexfoliation syndrome Artificial heart valve Pregnancy or planning a pregnancy Artificial joints within past two years Defibrillator Flomax MRSA Pacemaker Premedication prior to procedures Rapid heart beat with epinephrine Other Symptoms ________________________________________________________________

INFORMATION REGARDING DILATING EYE DROPS AND CONSENT TO TREAT

Dilating drops are used to enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye. These drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for your ophthalmologist to predict how much your vision will be affected. I understand that if my pupils are dilated, I may not be able to safely operate a motor vehicle and that the staff and doctors of Hill Country Eye Center recommend that I find alternate transportation. I have requested medical services from Hill Country Eye Center for myself or my child. I agree to and understand that my/my child’s eyes may be dilated in order for the doctor to thoroughly check the retina. I hereby authorize Dr. Restivo, Dr. Shepler, Dr. Wollan or Dr. Osterman and/or his assistants which may be designated by him to administer dilating eye drops. These drops are necessary to diagnose my condition, if any exists. Patient Signature: __________________________________________ Date _______________

Clinic Representative: ______________________________________ Date _______________

FINANCIAL POLICY Hill Country Eye Center will file claims to your medical insurance, when applicable, as a courtesy to you. It is important for you to understand that the contract exists between you and your medical insurance carrier. Hill Country Eye Center will attempt to verify your benefits and coverage prior to your visit, however, there is no guarantee that your insurance company will pay for services rendered by our facility. We require that co-pays, applicable deductibles and coinsurance be paid at the time of service. We will attempt to provide an estimate of the charges at time of service. If a balance is incurred we will send you a statement for any outstanding balance. We will not bill vision insurance as we are not providers for those plans. Private pay patients are expected to pay in full at the time of service unless prior arrangements have been made. You will receive a prompt pay discount on services provided when paid at time of service. Routine vision may or may not be covered by your medical insurance plan. We will attempt to verify coverage for routine eye exams before your visit. If there is no medical diagnosis found during your exam, and your insurance company does not provide routine coverage, you will be responsible for the charges. Hill Country Eye Center maintains a returned check fee policy of $30. Any patient with two returned checks will no longer be able to pay by check. Additionally, we also may charge a no show fee of $25 for each appointment without a 24 hour notice of cancellation. ASSIGNMENT OF BENEFITS I understand that I am fully financially responsible for any and all charges incurred during the course of authorized treatment. I further understand that all applicable fees are due on the date that services are provided and agree to pay such charges in full. I hereby assign all medical and surgical benefits to Hill Country Eye Center, including major medical benefits, to which I am entitled. I authorize and direct my insurance carrier(s) to issue payment checks to Hill Country Eye Center for medical services rendered to myself or minor children. I understand that I am responsible for any amount not covered by my insurance benefits. AUTHORIZATION TO RELEASE INFORMATION I authorize Hill Country Eye Center to disclose protected health information, including lab results and diagnoses, in messages left on my voicemail at the following number (____) _____-______, and to the following person(s) _________________. I authorize Hill Country Eye Center to release any information necessary to insurance carriers regarding my treatments, process insurance claims generated in the course of examination, and allow a photocopy of my signature to be used to process insurance claims for the period of my lifetime. ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES I have reviewed Hill Country Eye Center’s Notice of Privacy Practices provided behind this paperwork, which describe how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document if I ask for one. Patient Signature: __________________________________________ Date _______________

Clinic Representative: ______________________________________ Date _______________