New Patient Adult Packet Form

Patient Information Form

HIPAA Release Form

SPEARFISH EYE CARE CENTER
Dr. Kathy Haivala
Dr. Tim Robinson

Custom Field

I authorize the release of all examination information and financial information to the following: I do not authorize the release of any exam/financial information.

Relation

Spouse Child Other

Relation

Spouse Child Other

Relation

Spouse Child Other

Relation

Spouse Child Other

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES In the course of providing service to you we create, receive and store information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct healthcare operations involving our office. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail.

This Release of Information will remain in effect for five years unless terminated by me in writing.

PERSONAL MEDICAL HISTORY {New Patient) Review of Systems:

Please check If any of the following applies to you, past or presents

Constitutional

Cancer Trauma/Large Volume Blood Loss Developmental Disability Other

Hermatological

Anemia Leukemia Other

Gastrointestinal

Crohn's Desease Colitis Other

Ear/Nose/Throat

Hearing Loss Upper Respiratory Infection Other

Genitourinary

Benign Prostate Disease Kidney Disease Chronic Urinary Tract Infection Other

Allergies (please list)

Alcohol Use?

Yes No

Tobacco Use?

Current Past Never

Have you ever been treated oral prednisone?

Yes No

FAMILY HISTORY

Has anyone in your immediate family (grandparent, parent, sibling, children, living or deceased - please note maternal of paternal) been diagnosed with:

Disease/Condition

Blindness (injury related)

Yes No

Cataract

Yes No

Glaucoma

Yes No

Crossed Eyes

Yes No

Macular Degeneration

Yes No

Retinal Detachment

Yes No

Hypertension

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Thyroid

Yes No

Cancer (include type)

Yes No

Have you ever had any eye injuries?

Yes No

Have you ever had any eye surgeries?

Yes No

Have you ever taken any eye medications?

Yes No

Are you currently pregnant or nursing?

Yes No

Demographic Information

Marital Status

Married Single Divorces Widowed

Preferred method of contact

E-mail Cell Phone Home Phone Mail

Is texting okay

Yes No

Ethnicity

Declined to Specify Hispanic or Latino Not Hispanic or Latino Native Hawaiian or Pacific Islander

If you had your last exam here and purchased glasses here, PLEASE SKIP QUESTIONS 1 AND 2 BELOW

Do you wear contacts?

Yes No All the time Sometimes

Wearing Schedule

Daily Overnight

Please do not submit any Protected Health Information (PHI).

Location

Find us on the map

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Spearfish Eye Care Center

Address

1710 North Ave
Spearfish, South Dakota 57783, US

Contact Information (605) 642-8480

(605) 642-8185

[email protected]

Hours of Operation

Spearfish Eye Care Center

Monday

8:00 am - 5:30 pm

Tuesday

8:00 am - 5:30 pm

Wednesday

8:00 am - 5:30 pm

Thursday

8:00 am - 5:30 pm

Friday

8:00 am - 5:30 pm

Saturday

Closed

Sunday

Closed

New Patient Adult Packet Form

Patient Information Form

HIPAA Release Form

SPEARFISH EYE CARE CENTER Dr. Kathy HaivalaDr. Tim Robinson

Demographic Information

Location

Find us on the map

Hours of Operation

Spearfish Eye Care Center

SPEARFISH EYE CARE CENTER
Dr. Kathy Haivala
Dr. Tim Robinson