Injury/trauma/emergency Intake Form
ADVERTISEMENT
1SOUTHERN EYE ASSOCIATES
INJURY/TRAUMA/EMERGENCY INTAKE FORM
Chart Number: _____________
Legal Name
SS#:
: ______________________________________________________
_________________________
LAST
FIRST
MI
Address:
City_________________ State: ____________ Zip: ________
______________________________
Tel Home: ____________________Cell: ________________ Email: ________________________________
Sex: □ M
□ F
Birth date (Mo/Day/Yr): _______________ Age: _____
employed: □ Yes □ No
□Fulltime
□Part-time
□ Yes □ No
Is patient
Is patient a student:
INSURANCE INFORMATION:
During the case of an emergency and/or trauma we will do our best to accommodate a physician who is
1.
in your insurance network. However, due to availability and the physician who is treating emergencies
that day this may not always be available. We will file your insurance as a courtesy, however if for any
reason the treating physician is not contracted with your insurance you will be responsible for the cost of
the visit. We will provide you with the necessary information to file your claim to your insurance
company to seek direct reimbursement
We will ONLY file Medical Insurance for Injury and/or Trauma Visits—we cannot file your Vision
2.
Insurance as these visits are medical in nature
Insurance claims have to be paid timely, therefore if the insurance balance is unpaid after 30 days you
3.
will be responsible and you can seek reimbursement directly from your insurance carrier
HISTORY OF PRESENT ILLNESS
Is your visit related to a work accident or worker’s compensation claim?
□ No □ Yes
Date of Injury ________
(if yes, please complete additional form)
Is your visit related to an injury or trauma? □ No □ Yes
Date of Injury ___________
Background Information:
□ No □ Yes
1. Is this the first time we are seeing you in this office for this issue?
□ No □ Yes
2. Has this issue ever happened before?
3. Give a brief description of why you are being seen in the office today:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Which eye(s) is troubling you?
LEFT EYE
RIGHT EYE
BOTH
5. When did you first notice this issue? ______________________________________________________
6. Have you sought previous medical treatment for this issue? ____________________________________
If so, where and when? ________________________________________________________________
Name of Physician:
________________________________________________________________
7. On the scale of 0 – 10, what is your current pain level (0 being no pain, 10 being the worse pain)?
0
1
2
3
4
5
6
7
8
9
10
Name (print): _______________________________________ Date: __________________
Patient / Guardian / Guarantor Signature: ______________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business