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I'm a new patient

I've been seen in the last 1-3 years

New Patients

How did you hear about us?
- Dr. Crosby Patient
- Doctor Referred
- Another Patient
- Internet Search
- Staff Member
- Word of Mouth
- Insurance Co.
Name of Referring Dr.
Who Can We Thank For the Referral?
Which Staff Member Referred You?
Name*
Prefix First Middle Last Suffix
Nickname
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
SSN*
Maiden/Previous Name
Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is someone other than the Patient responsible for the bill (such as a parent)?*
- Yes
- No
Responsible Party*
First Last
Responsible Party Phone Number*
Relationship to Responsible Party*
Address*
- Yes
- No
Address of Responsible Party*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone
Home Phone
Work Phone
Other Phone
Email
You Authorize us to text or leave a message on the numbers above or email you.
Check box to opt-out
Primary Number
- Home
- Work
- Mobile
Secondary Number
- Home
- Work
- Mobile
Automated Appointment Reminders
- Opt out of automated appointment reminders
Primary Care Doctor
Race
Marital Status
- Single
- Married
- Widowed
- Divorced
- Minor
Are you hispanic or latino?
- Yes
- No
Language
- English
- Spanish
Is the Patient?
Work Status*
- Employed
- Full time student
- Homemaker
- Part time Student
- Retired
- Unemployed
Employer
Occupation
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please provide your insurance cards at check in.
Primary Medical Insurance
Primary Medical Insurance Member ID Number
Secondary Medical Insurance
Secondary Medical Insurance Member ID Number
Vision Insurance
Vision Insurance Member ID Number
Were you injured on the job?*
- Yes
- No
Date of Injury*
MM slash DD slash YYYY
Did you report the injury to your employer?*
- Yes
- No
Authorization and Assignment

I authorize Georgia Eye, LLC to release medical records to any insurance company with whom I have medical or vision benefits, or to my employer, for the purpose of filing medical claims. I also authorize any physician, hospital, or clinic to provide medical information required in the course of my examination or treatment. I give consent for Georgie Eye, LLC physicians to obtain prescription history from external sources.

I consent to medical treatment for myself or for the patient for whom I am the parent or legally authorized representative.

Insurance is filed as a courtesy. It is the patient/guardian responsibility to ensure all bills are paid. All co-pays, deductibles, and co-insurance are due at the time or services. Surgical estimates are due a week prior to surgery.

Assignment of Benefits Payment: I authorize my health insurance benefit plan to pay directly to Georgia Eye. I understand that I am financially responsible for any non-covered charges. If I am a self-pay patient, I understand that I am responsible for all charges in full at the time of service. I have read and understood the Financial Policy terms and conditions effective 1/2/2020.

I acknowledge I have received the Notice of Privacy Practices and Notice of Individual Rights. Georgia Eye may release information to the following people:
Name
Name
Relationship
Phone
Name
Name
Relationship
Phone
Patient or Guardian Signature*
Date*
MM slash DD slash YYYY

Medical History

Name
First Last
Date of Birth
MM slash DD slash YYYY
What is the reason for your visit today?
Do you wear?
- Glasses
- Contacts
- Neither
Do you have difficulty reading?
- Yes
- No
Do you CURRENTLY have any EYE SYMPTOMS?
- None
- Eyepain
- Blurred Vision
- Eyelid Crusting
- Flashes of Light
- Halos
- Floaters
- Discharge
- Light Sensitivity
- Double Vision
- Decreased Vision
Check all that apply
List any EYE PROBLEMS current or past
If none, leave blank
Do you currently use EYE DROPS?
- Yes
- No
Please list any EYE DROPS you currently take
List any MEDICAL CONDITION you CURRENTLY have
such as: high blood pressure, high cholesterol, diabetes, heart disease, cancer, auto-immune disease, immune deficiency, organ transplant, etc.
List any MEDICAL CONDITIONS you had in the PAST
List any EYE DISEASES you have ever had
Such as: glaucoma, cataract, wandering or 'lazy' eye, retinal detachment, etc.
List any EYE INJURY you have had
List any EYE SURGERY including type, which eye and approximate dates
List any PRIOR SURGERY other than eye surgery
List any HOSPITALIZATION including date and reason
List any MEDICATIONS you currently take
What's the name and location of your PHARMACY?
List any drug or food ALLERGIES
List any EYE DISEASES THAT RUN IN YOUR FAMILY
Such as: glaucoma, macular degeneration, cataract, diabetic retinopathy
List any HEALTH PROBLEMS THAT RUN IN YOUR FAMILY
Such as: diabetes, cancer, auto immune deficiency
Do you drink alcohol?
- Yes
- No
How Much?
Have you ever smoked?
- Yes
- No
How much?
Have you ever used recreational drugs?
- Yes
- No
What type and When?
Are you employed?
- yes
- no
How many hours a week do you work?
Are you interested in finding out about refractive surgery (LASIK)?
- Yes
- No
Signature
Date
MM slash DD slash YYYY

Connect With Us!

Office Hours / Contact

Mon-Wed 7:30am-6:00pm
Th – Fri 7:30am-4:30pm

Ph 706.546.0170
Fax 706.546.5015

Athens

140 Trinity Place
Building B
Athens, GA 30607
Get Directions

Greensboro/Lake Oconee

1030 Founders Row
Greensboro, GA 30642
Get Directions

Services

Cataract Surgery | Family Medical Eye Care | Glaucoma Treatment | Treatment of Macular Degeneration | Complete Diabetic Eye Care | Eyelid Surgery

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