Brett Elliott, MD                  Date________________     

Patient's Name _______________________________________________Birth Date_______
Home Address _________________________________________________Phone____________
Employer______________________________________________________
Business Address _____________________________________________Phone____________
Occupation____________________________ Referred by_____________________________

Method of Payment Check _____ Cash _____.  We do not accept credit cards.
      Deductibles and co-payments need to be paid at the time of service.

PLEASE ANSWER THESE QUESTIONS                                           YES  NO

Are you having trouble with your eyes?                                  ___ ___
If so, what is the nature of the trouble and when did it begin?__________   

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Have you ever worn glasses or contacts in the past?                     ___ ___
Do you wear glasses or contacts now? (Circle appropriate one)              
How long have you been wearing your present prescription?_________________

Do you have a family history of eye diseases?                           ___ ___
If so, what are they______________________________________________________

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Are you being treated illnesses? (eg. diabetes, heart condition)        ___ ___
If so, which ones_________________________________________________________

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Are you taking any medications?                                         ___ ___
If so, which ones_________________________________________________________

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Are you allergic to any drugs?                                          ___ ___
If so, which ones_________________________________________________________

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Have you ever had any major operations?                                 ___ ___
If so, what were they_____________________________________________________

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Address of Family Physician: __________________________________
                             __________________________________
                             __________________________________
Additional Remarks______________________________________________________________________

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  I authorize and request my insurance company to pay directly to the doctor insurance benefits due me. I understand 
that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all 
services rendered on my behalf or my dependents. Regulations pertaining to Medicare assignment of benefits apply.

    As required by federal regulations I have received a copy of Brett Elliott, MD PA's Notice of Privacy Practices.

Signature of patient or guardian:___________________________________ Date: ____/____/____