Patient Questionaire | Truway Vision Care

Name*

First MI Last

Address

Street Address City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email

Gender*

Date Of Birth

Social Security #

Primary Insurance Company

Policy ID #

Policy Holders Name

Date Of Birth

Medical Information

Do you have problems with any of the following? (Check all that apply)

Allergic to any Medication?

LIst all medications you are currently taking

List all major injuries/ surgeries you have had

Do you currently

Smoke Cigarettes /or use Tobacco
Drink Alcohol
Use Illegal Drugs

Have you ever been exposed/infected with

Gonorrhea
Hepatitis
HIV

Name of Primary Doctor

Office Numer

Date of Last Visit

Personal Eye History

Do You have any of the following? (check all that apply)

Family History

Anyone in your family suffer from (check all that apply)

High Blood Pressure
Diabetes
Glaucoma
Macular Degeneration
Retinal Detachment
Cataract

Assignment and Release

Consent*

I, THE UNDERSIGNED, CERTIFY THAT MY INSURANCE COVERAGE IS WITH_______________________AND ASSIGN
DIRECTLY TO TRUWAY VISION CARE ALL INSURANCE BENEFITS FOR THE SERVICES RENDERED. I
UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY
INSURANCE. I HEREBY AUTHORIZE TRUWAY VISION CARE TO RELEASE ALL INFORMATION NECESSARY TO
SECURE THE PAYMENT OF BENEFITS. I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE
SUBMISSIONS.

I agree to the privacy policy.

Initial Here*

Date*

Comments

This field is for validation purposes and should be left unchanged.