Welcome to Davies Eye Center! 25 Years of Innovative Care James A. Davies, MD, F.A.C.S 655 Laguna Drive Carlsbad, CA 92008 760-729-7101 Our Mission Statement & Values We are dedicated to providing quality Opthalmic medical services in a caring and professional atmosphere. The entire team at Davies Eye Center is committed to service, innovation, and quality care, while serving the needs of the community. The Davies Eye Staff Dr. James Davies, M.D. is the Medical Director of Davies Eye Center and Surgical Eye Care Center, located in Carlsbad. As a surgical pioneer, Dr. Davies has been recognized as the authority in the field of cataract and refractive surgery with experience in a wide range of procedures, such as Corneal and Anterior Segment Eye Surgery, Corneal Laser Refractive Surgery, LASIK, and
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Welcome to Davies Eye Center! · 2017-02-08 · Welcome to Davies Eye Center! 25 Years of Innovative Care James A. Davies, MD, F.A.C.S 655 Laguna Drive Carlsbad, CA 92008 760-729-7101
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Welcome to Davies Eye Center!
25 Years of Innovative Care
James A. Davies, MD, F.A.C.S
655 Laguna DriveCarlsbad, CA 92008760-729-7101
Our Mission Statement & Values
We are dedicated to providing quality Opthalmic medical services in a caring and professional atmosphere. The entire team at Davies Eye Center is committed to service, innovation, and quality care, while serving the needs of the community.
The Davies Eye Staff
Dr. James Davies, M.D. is the Medical Director of Davies Eye Center and Surgical Eye Care Center, located in Carlsbad. As a surgical pioneer, Dr. Davies has been
recognized as the authority in the field of cataract and refractive surgery with experience in a wide range of
procedures, such as Corneal and Anterior Segment Eye Surgery, Corneal Laser Refractive Surgery, LASIK, and
Making the Most of Your First Appointment
Davies Eye Center Patient Education
3) List all of your current Medications and Allergies
4) Complete the Review of Systems to mark any current or ongoing
5) Read, initial, and sign the Patient Agreement
GETTING TO KNOW YOU
1) Complete the New Patient Form
2) Complete the Patient Health History Form
symptoms you are experiencing
We'd like to help you get the most out of your first visit with Dr. Davies. Your time with him is valuable and we have a few suggestions to help you make the most of your visit.
To begin with, we ask that you complete the New Patient Information forms included in this Welcome Package before you come in to see Dr. Davies for your first visit. Please make sure you:
Please bring the completed forms and all insurance cards with you to your first visit. If you have any questions or would like assistance in completing any of these forms mentioned above, please call 760.729.7101 and we'd be glad to help.
Talk about your medications Talk about serious problems Don't be afraid to ask questions Review our Educational Videos on topics like Cataracts, Advanced Laser
Davies Eye Center offers many educational programs to the community, most of which are free of charge. Classes cover many topics and are generally open to anyone who wishes to attend, whether they are Davies Eye Center patients or not. Additionally, we offer a select number of courses for specific medical conditions that require a referral from your primary care provider.
Patient Last Name: First: Middle Initial: DOB:
Address: City: State: Zip:
SSN: Cell Phone: ( ) Home Phone: ( )
Gender: Male Female Marital Status: Single Married Separated Divorced Widowed
Race: Caucasian Asian American Indian/Alaska Native Black/African American
Hawaiian/Pacific Islander Hispanic/Latino Other Unknown
Preferred Language: Do you have a translator? Yes No
Emergency Contact: Phone: ( )
Relationship to Patient: Yes, you may discuss my medical information with this person.
EMAIL ADDRESS: May we send you information by email? Yes No
Primary Care Physician: Please send my exam notes to this Doctor
Phone: ( ) Fax: ( )
Optometrist: Please send my exam notes to this Doctor
Phone: ( ) Fax: ( )
Other Doctor: Please send my exam notes to this Doctor
Phone: ( ) Fax: ( )
Preferred Pharmacy Name:
Phone: ( ) Fax: ( )
Street Address: City:
How did you hear about us?
My Optometrist or other Doctor…Name?
Another Davies Eye Patient…Name?
Internet Search…Which website or What search words did you use?
Health Fair or Eye Screening…Location?
Newsletter or Magazine Ad…Which One?
Radio….Which Station?
Other…Please describe:
PATIENT SIGNATURE: DATE:
PHARMACY INFORMATION
REFERRAL SOURCES
AUTHORIZATION
I authorize DAVIES EYE CENTER to release my name in thanking the above named patient/friend/family member. I also authorize the release
of any medical information necessary to process all claims, including Medigap, and the release of payment of medical benefits to my physician.
AS A COURTESY TO ME, DAVIES EYE CENTER WILL BILL MY INSURANCE COMPANY. IF MY INSURANCE COMPANY HAS NOT PAID THE CLAIM
FOR WHATEVER REASON, WITHIN 60 DAYS OF TREATMENT, I AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED. NOTE:
Medicare and other insurance providers typically do not cover reactive testing/procedures. You may be required to pay out of pocket for
these services.
NEW PATIENT FORM
PATIENT INFORMATION
DOCTOR INFORMATION
PATIENT NAME: DOB: Date:
Smoking Status? Current Smoker Occasional Smoker Former smoker Never smoked
Drink Alcohol? 3+ drinks per day 1-2 drinks per day Less than 1 drink per day None
Patient feels safe at home? Yes No If No, please explain: ________________________________________________________
Check ALL that apply:
Blindness Diabetes Hypertension
Cancer Glaucoma Macular Degeneration
Cataracts Heart Disease Retinal Detachment
Please check the following medical conditions that you CURRENTLY have:
Anxiety Depression Leukemia
Arthritis Diabetes - Insulin? Yes No Lung Cancer
Asthma End Stage Renal Disease Lymphoma
Atrial Fibrillation GERD Prostate Cancer
BPH (prostate) Hearing Loss Radiation Treatment
Bone Marrow Transplant Hepatitis Seizures
Breast Cancer Hypertension (High Blood Pressure) Stroke
Colon Cancer HIV/AIDS Hypothyroidism
COPD Hypercholesterolemia
Coronary Artery Disease Hyperthyroidism
None Apply
Check ALL that apply:
Appendix (Appendectomy) Gallbladder Skin
Bladder (Cystectomy) Heart Spleen
Breast: Lumpectomy R / L Joint Replacement: Knee R / L Uterus (Hysterectomy)
Mastectomy R / L Hip R / L Other (Please List):
Reduction R / L Kidney
Implants R / L Ovaries
Colon Prostate
None Apply
Check ALL that apply:
Allergic Conjunctivitis Dry Eyes Ocular Migraines
Blepharitis Glasses Retinal Detachment
Cataracts Glaucoma Retinal Tear
Contact Lenses Macular Degeneration Strabismus
Diabetic Retinopathy Narrow Angles Floaters
None Apply
Check ALL that apply:
Blepharoplasty Eye Muscle Glaucoma
Cataract Surgery Dates: LASIK/PRK: Retinal
Right Eye: _________ Right Eye: _________ Corneal Transplant
Left Eye: _________ Left Eye: _________ None Apply
PATIENT INITIALS:
PATIENT HEALTH HISTORY
SOCIAL HISTORY
FAMILY HISTORY
OCULAR HISTORY
OCULAR SURGERY
Other (Please List):
SURGICAL HISTORY
PATIENT NAME: DOB: Date:
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PATIENT INITIALS:
PATIENT HEALTH HISTORY
MEDICATIONS
MEDICATION NAME DOSAGE FREQUENCY
ALLERGIES
MEDICATION/ANESTHESIA NAME REACTION
Please list ALL medications you are currently taking with their dosages and frequency. Include any vitamins and supplements.
Please list any and all medications you are allergic to and the reactions.
PATIENT NAME: DATE:
NAME SYSTEM YES NOPoor Vision Eyes m m
Eye Pain Eyes m m
Tearing Eyes m m
Redness Eyes m m
Jaw Pain Eyes m m
Scalp Tenderness Eyes m m
Amaurosis Fugax (Fleeting Blindness) Eyes m m
Loss of Vision Eyes m m
Fever Constitutional/Symptom m m
Chills Constitutional/Symptom m m
Weight Loss Constitutional/Symptom m m
Stuffy Nose ENT and Mouth m m
Ear Ache ENT and Mouth m m
Cough ENT and Mouth m m
Dry Mouth ENT and Mouth m m
High Blood Pressure Cardiovascular m m
Rapid Heart Beat Cardiovascular m m
Congestion Respiratory m m
Wheezing Respiratory m m
Shortness of Breath Respiratory m m
Upset Stomach Gastrointestinal m m
Diarrhea Gastrointestinal m m
Constipation Gastrointestinal m m
Burning on Urination Genitourinary m m
Urinary Frequency Genitourinary m m
Incontinence Genitourinary m m
Joint Pain Musculoskeletal m m
Stiffness Musculoskeletal m m
Arthritis Musculoskeletal m m
Rash Integumentary m m
Changing Moles Integumentary m m
Headache Neurological m m
Seizure Neurological m m
Stroke Neurological m m
Paralysis Neurological m m
Anxiety Psychiatric m m
Depression Psychiatric m m
Insomnia Psychiatric m m
Diabetes Endocrine m m
Thyroid Abnormalities Endocrine m m
Bleeding Hematologic/Lymphatic m m
Anemia Hematologic/Lymphatic m m
Allergies Allergic/Immunologic m m
Hay Fever Allergic/Immunologic m m
Hives Allergic/Immunologic m m
CONTINUED ON BACK
REVIEW OF SYSTEMS
Please respond based on current or ongoing symptoms you are experiencing.