KIDSEYES | DR CLAIRE CULLEN

Patient Medical History:

Person Responsible for account:

MEDICAL QUESTIONAIRE

Patient Ocular History:
Please tick either YES or NO for the following questions.
If you tick yes please provide details
If you checked no then enter N/A under details
If you are unsure of the question check no and enter "Unsure" under details

Wear glasses/contacts now/past: Yes No

Ocular medication: Yes No

Previous strabismus: (squint) Yes No

Previous amblyopia: (lazy eye) Yes No

Previous eye surgey : Yes No

Glaucoma: Yes No

Cataracts: Yes No

Retinal disease: Yes No

Diabetic eye disease: Yes No

Corneal problems: Yes No

Other: Yes No

Double vision: Yes No

Patient Medical History:

Medications: Yes No

Allergies: Yes No

Respiratory problems: (e.g. asthma) Yes No

Heart problems: Yes No

Hematologic problems: (anemia, bleeding, etc.) Yes No

Kidney or Urinary Problems: Yes No

Neurologic Problems: (headaches, seizures, hydrocephalus etc.) Yes No

Infectious diseases: Yes No

Endocrine Problems: (diabetes, thyroid, etc.) Yes No

Rheumatological disease: (arthritis etc) Yes No

Cancer: Yes No

Problems with anaesthesia: Yes No

Other: Yes No

Previous surgery: Yes No

Family History: (does anyone in your immediate family have any of the below)

Diabetes: Yes No

Thyroid disease: Yes No

Strabismus or lazy eye: Yes No

Heart disease: Yes No

High blood pressure: Yes No

Other: Yes No

I, the undersigned do hereby ACKNOWLEDGE:

That all fees must be settled immediately after each consultation, and that I will be liable for payment of the fees plus interest calculated from the date of default at the rate determined by law. I further acknowledge that any legal costs incurred by the doctor on account of legal action instituted to recover any outstanding fees from me, will be for my account.
That a statement reflecting my full payment will be issued and it is my duty to submit it to the medical aid for reimbursement.
Accept that each consultation visit is charged for separately.
That it is my responsibility to obtain authorization from my service provider for all procedures.
Accept that any and all appointments not kept will be charged for in full
Give permission for a medical report to be provided to the referring optician/ medical doctor.
We are a cash practice and all consultations must be paid via cash or credit/debit card after the consultation

BILLING POLICY 2020

FIRST CONSULTATION/YEARLY FOLLOW-UP: R1750.00.
FOLLOW- UP CONSULTATION WITHIN 3 months: R700.00 per consultation
FOLLOW- UP CONSULTATION 4-11 months: R1200 per consultation
No telephonic consultations will be conducted.
In an emergency please present yourself or your child to the nearest Hospital casualty department.

Signature:

Agree
By ticking the box below the electronic signature, you acknowledge that you have signed the document electronically and have agreed to the terms and conditions

FIRST VISIT FORM ADULT PATIENT