404.239.0272

Dr. Alan L. Hymowitz, Chief Optometrist

make an appointment

Giving Sight

We are providers for most major medical insurance plans as well as vision insurance plans.

404.239.0272

Appointments

Dr. Alan Hymowitz - OD

You may schedule an appointment by calling our office or
REQUEST an appointment date & time by filling out the following information.

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NOTE: Appointment times are subject to availability. We will do our best to accommodate your request. Our office will contact you by phone or by email to confirm your appointment.

I wish to fill out my insurance and medical history information now to save time.

Insurance Information

Medical Insurance Company

Medical Policy #

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Medicare #

Vision Insurance Company

Vision Policy #

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Referred by:

Is this your first visit to our office:

Yes

Reason For Your Office Visit:Ã‚Â (Check all that apply)

	Exam	Glasses
	Contacts	Eye Infection or Injury
	Medical Problem	Laser Vision Consultation
Other

Are you planning to get new glasses on this visit?

Yes

If Necessary

If you participate in any sports list them here:

Medical History Form

To help our office better serve your specific needs, please check all that apply. Please leave blank for a NO answer.

EYE HISTORY

Headaches	GlareLight Sensitivity	Tired Eyes
Eye Infection	Excess Tearing/Watering	Redness
Drooping Eyelid	Sandy or Gritty Feeling	Itching
Amblyopia(lazy eye)	Eye Pain or Soreness	Fluctuating Vision
Crossed Eyes	Dryness	Blurred Vision Distance
Floaters or Spots	Distorted Vision (halos)	Burning
Loss of Side Vision	Foreign Body Sensation	Loss of Vision
Macular Degeneration	Retinal Detachment	Glaucoma
Double Vision	Blurred Vision Near	Mucous Discharge
Color Blindness	Blindness	Diabetic Retinopathy
Cataract(s)	Other

GENERAL HEALTH CONDITION

Family Doctor's Name & Address:

Kidney	Fever	Muscles, Bones, Joints
Ears, Nose, Throat	Allergic	Respiratory (Asthma)
Neurological	Skin	Psychiatric
Weight Loss	Gastrointestinal	Blood/Lymph
Joint Pain	Endocrine	Cardiovascular Disease
Bleeding Problems	Anemia	Heart Disease
Diabetes	Genitals/Kidney/Bladder	Cancer
AIDS/HIV	Rheumatoid Arthritis	Emphysema
Pregnant or Nursing	Sinus Congestion	Runny Nose
Smoke Cigarettes	Post-Nasal Drip	Chronic Cough
Consume Alcoholic Beverages	Lupus	Stroke
Chronic Bronchitis	Dry Throat/ Mouth	Thyroid Disease
High Blood Pressure	Other System

FAMILY HISTORY

Stroke	Arthritis	Macular Degeneration
Amblyopia (Lazy Eye)	Cancer	Retinal Detachment
Glaucoma	Lupus	Crossed Eyes
Heart Disease	Kidney Disease	Thyroid Disease
High B.P.	Diabetes	Cataract(s)
Blindness	Color Blindness	Other

Currently taking medication(s) - (prescription and over the counter)

1. I take
	for this condition:
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If you take additional medications, please list them here.

Drug Allergies:

Yes

If yes, list the medications: