Cannon EyeCare at Pike Place Market, 1906 Pike Place #8, Seattle, WA 98101(206)448-7739

1(206)448-4924

PP@DrCannon.com

PATIENT INFORMATION

Last Name _____________________________ First __________________________M: __________________
Date of Birth _____________________ Last 4 of SS # ______ Nickname ____________________________
Address ________________________________ Apt# ________ City _________ State _____ Zip _________
Sex: M  F 

Marital Status:  Single  Married  Other

Occupation __________________________

Phone: Cell ____________________ Home __________________ Email ___________________________How did you learn about Cannon EyeCare? ________________________________________________________In Case of Emergency
Name ________________________ Phone # _______________________ Relationship _________________

2INSURANCE

Note: Cannon EyeCare is in network with Premera, Regence, HMA, Lifewise, Uniform, Blue Cross/Blue Shield, Medicare, and Kaiser PPO plans.

MedicalVisionInsurance Co _______________________________ My vision provider is the same as my medical

ID_______________________ Group # _________ My vision provider is one of the following:

Primary Insurance Account Holder / Subscriber:

 VSP  EyemedSelf  Other  ____________________________Name / D.O.B

 Davis Vision OtherYour vision insurance carrier may be different than your medical insurance
carrier. We do not accept independent vision insurance plans such as VSP,Eyemed, or Davis Vision. We will provide you with a claim form to selfsubmit for reimbursement.

Assignment and ReleaseI assign directly to Cannon EyeCare all insurance benefits for services rendered. I authorize release of all information necessary to secure thepayment of benefits. I authorize the use of this signature on insurance submissions.

Responsible Party Signature ________________________________

3Date ________________________ACKNOWLEDGEMENT OF HIPAA AND BILLING POLICIESI understand I have rights to privacy regarding my health info as protected by the Health Insurance Portability andAccountability Act of 1996 (HIPAA). I authorize Cannon EyeCare to use and disclose my protected health information to carryout: treatment and coordination of treatment with other providers, obtaining payment from my insurance company, and theoperation of the practice. I have been given the opportunity to review and take a copy of the Notice of Privacy Policies, whichcontains a more complete description of my rights under HIPAA.
I understand that insurance benefits quoted to me are not a guarantee of payment, that final determination of benefits will bemade by my insurance company, and that I am financially responsible for any balance due that is not covered by myinsurance. Cannon EyeCare does bill secondary insurance, but only when we are in network with both insurance companies.
Accounts 90 days past due may be sent to collections.

Responsible Party Signature ________________________________
Continued on back page

Date ________________________

4EYE HEALTH
Do You Wear Contacts?  Yes  No  Interested

What is the main reason for your visit today?

______________________________________________________________________________

Brand_______________________________________________________________________________

Describe any problem you have with your contacts: _____________________________________________________

Last Eye Exam_________ Last Dilation _______
Do you wear Glasses?  Yes  NoScreen Time

Have you ever had any eye surgery?

 All the time Occasionally 1-4h  8-12h

 Cataract

 Driving Reading 4-8h  12+h

Do you currently take any eye medications or drops?

 RK

 Lasilk / PRK Other____________________________________________________________Are you currently experiencing any of the following with your eyes?
 Blurred Vision

 Flashes of light Burning Floaters

 Glare Itching Double Vision

 Redness Dry Eye Vision Loss

 Eye Strain

 Eye Lid Problems

 Crusting / Mucus

Have you or Family Member been diagnosed with the following?

YouFamily Member

Cataracts

 Yes  No

 Yes  No

 Eye Discomfort

Glaucoma Yes  No

 Yes  No

 Excessive Tearing

Macular Degeneration

 Yes  No

 Yes  No

Other eye conditions

 Yes  No

 Yes  No

Other _______________________________________

5HEALTH HISTORYMark "Yes" or "No" to indicate if you or your immediate family (parents, grandparents, siblings) have had any of the following problems.

YouFamily Member

Diabetes Yes  No

 Yes  No

High Blood Pressure Yes  No

 Yes  No

Rheumatoid Arthritis Yes  No

 Yes  No

Thyroid problems

 Yes  No

 Yes  NoCancer

 Yes  No

 Yes  NoDermatitis Yes  No

 Yes  No

Currently Pregnant

 Yes  NoTobacco Use?

6

 Non-Smoker Light Smoker

 Moderate Heavy Former Smoker

MEDICATIONS

ALLERGIES

Please list any medications you are currently taking:7

Please list any other health conditions you have:

Taken For:

List any known medical allergies below:

REVIEW OF SYSTEMS Allergic/immunologic Neurologic  Psychological Cardiovascular Respiratory

 lntegumentary (skin) Endocrine Blood Disorders

 Ears, Nose, Throat, Mouth Musculoskeletal