MOUNTAINEER VISION CENTER, PLLC

DR. MARK D. ROBINSON DR MICHAEL R. LOOPER

827 Fairmont Road, Suites 105-106 - Morgantown, WV 26501
Phone: (304) 296 – 3333; Fax: (304) 296 – 2220
http://www.mvcpllc.com

MEDICAL HISTORY
PATIENT’S NAME: _________________________________________________ DATE: _______________________

- PART ONE -
DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS?

CONDITION YES NO MEDICATIONS HOW LONG

HYPERTENSION
HEART DISEASE
STROKE
DIABETES
THYROID DISEASE
ARTHRITIS
SINUSITIS
EMPHYSEMA
ASTHMA
KIDNEY DISEASE
HEADACHE
HEAD INJURY
LIVER DISEASE
SEIZURES/TREMORS
LUPUS
ROSACEA
HIGH CHOLESTEROL
CANCER

- PART TWO -
DO YOU HAVE ANY OF THE FOLLOWING EYE CONDITIONS?

CONDITION YES NO MEDICATIONS HOW LONG

GLAUCOMA
MACULAR DEGENERATION
CATARACTS
RETINAL DETACHMENT
EYE INJURIES
EYE SURGERIES
BLINDESS
LAZY EYE

DO YOU HAVE DRY EYES? YES NO

DO YOU HAVE AIRBORNE ALLERGIES? YES NO LIST ALL ALLERGY MEDICATIONS BELOW:

________________________________________________________________________________________

ARE YOU ALLERGIC TO ANY MEDICINES? YES NO IF YES, PLEASE LIST BELOW:

________________________________________________________________________________________

Reviewed By: _________ Date: ________

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 - PART THREE -
DO ANY OF YOUR FAMILY MEMBERS HAVE ANY OF THESE MEDICAL CONDITIONS?

CONDITION YES NO WHICH FAMILY MEMBERS

HYPERTENSION
HEART DISEASE
STROKE
DIABETES
GLAUCOMA
CATARACT
RETINAL DETACHMENT
EYE SURGERIES
BLINDNESS
MACULAR DEGENERATION

- PART FOUR -
GENERAL QUESTIONS TO ASSIST US IN MEETING YOUR NEEDS AND CONCERNS.
 PLEASE LIST THE REASON(S) FOR YOUR VISIT TODAY:

_________________________________________________________________________________________

 DO YOU WANT (PLEASE CIRCLE ONE) GLASSES CONTACT LENSES BOTH

 ARE YOU PREGNANT? (PLEASE CIRCLE) YES NO

 DO YOU SMOKE? (PLEASE CIRCLE) YES NO

 DO YOU USE BIRTH CONTROL? (PLEASE CIRCLE) YES NO

- PART FIVE -

PATIENT INFORMATION – PLEASE FILL OUT FULLY & COMPLETELY. THANK YOU.

PATIENT’S INFORMATION

FIRST NAME: _____________________________ MI: _____ LAST NAME: ____________________________

ADDRESS: __________________________________________________________________ APT #: ________

CITY: ________________________________________ STATE: ________ ZIP CODE: _______________

HOME PHONE: _________________ WORK PHONE: ________________ CELLPHONE: _________________

E-MAIL: ____________________________________________________________________________________

OCCUPATION: ______________________________ DATE OF BIRTH: __________________ AGE: _________

EMPLOYER/SCHOOL: _____________________________________________ GENDER: MALE FEMALE

SOCIAL SECURITY NUMBER: ____________________________________________________

FAMILY DR.: __________________________________ FAMILY DR. PHONE #: _______________________

Reviewed By: _________ Date: ________

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 REFERRAL INFORMATION

HOW DID YOU HEAR ABOUT US? (CIRCLE ONE)

YELLOW PAGES NEWSPAPER AD FRIEND/CO-WORKER / NAME: _____________________

DAILY ATHENAEUM MVC, PLLC WEBSITE WALKED IN TO CENTER OTHER: ________________

DO YOU HAVE A COUPON? YES NO (IF YES, PLEASE PRESENT TO RECEPTIONIST.)

INSURANCE CARRIER INFORMATION

MARITAL STATUS (PLEASE ONLY CIRCLE ONE): SINGLE MARRIED DIVORCED

LEGALLY SEPERATED WIDOWED

PRIMARY VISION INSURANCE: ________________________________ ID #: _____________________

WHO IS THE PRIMARY POLICY HOLDER? SELF OTHER: ___________________________________

SECONDARY VISION INSURANCE: ______________________________ ID #:_____________________

WHO IS THE PRIMARY POLICY HOLDER? SELF OTHER: __________________________________

PRIMARY MEDICAL INSURANCE: ______________________________ ID #: _____________________

WHO IS THE PRIMARY POLICY HOLDER? SELF OTHER: __________________________________

-- PART SIX –

PATIENT FINANCIAL RESPONSIBILITY – PLEASE READ CAREFULLY AND SIGN BELOW. THANK YOU.

I, HEREBY AUTHORIZE MOUNTAINEER VISION CENTER, PLLC TO APPLY FOR BENEFITS ON MY

BEHALF FOR COVERED SERVICES RENDERED BY THEM. I ALSO ASSIGN MY BENEFITS AND REQUEST
THAT ALL PAYMENTS FROM MY INSURANCE COMPANY BE MADE DIRECTLY TO MOUNTAINEER
VISION CENTER, PLLC. I AGREE TO ASSUME RESPONSIBILITY OF FULL PAYMENT PENDING ANY
REMAINING BALANCE THAT IS NOT COVERED BY MY INSURANCE COMPANY.
I CERTIFY THAT THE INFORMATION I HAVE REPORTED WITH REGARD TO MY COVERAGE IS
CORRECT. I FURTHER AUTHORIZE MOUNTAINEER VISION CENTER, PLLC TO RELEASE TO MY
INSURANCE AND ITS AGENTS ANY INFORMATION RELATED TO THIS OR ANY RELATED CLAIM.

________________________________________________________________________________________
PATIENT/GUARDIAN SIGNATURE DATE

________________________________________________________________________________________
PATIENT/GUARDIAN PRINTED DATE

Reviewed By: _________ Date: ________

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