Call us directly: (321) 253-9228

278 N. Wickham Rd, Melbourne View Location

Online Forms

For your convenience, our forms are available below. Please fill out the entire form and submit at least 24 hours before scheduled appointment time. Please arrive for appointment 20 minutes early and bring all Insurance cards.

PATIENT INFORMATION FORM
MICHAEL K. GROFIK O.D., P.A.
278 N. Wickham Road
Melbourne, FL 32935
(321) 253-9228

Date: //

Last Name: First Name:

Address:

City: Zip:

DOB: //

SSN#:

Phone #: Alternate Phone:

Race:

Hispanic:

Preferred Language:

Marital Status:

Employer & Occupation:

Primary Care Physician:

Pharmacy:

Please list authorized persons for pick up of prescriptions and products
1.
2.
3.
4.

Do we have permission to leave messages?

Phone #: Alternate Phone:

Email:

Vision Insurance:

Provider: Insured ID#:

Primary Insurance Holder Name:

DOB: //

SSN#:

Relationship to Patient:

Plan Name: Group:


Medical Insurance:
Provider: Insured ID#:

Primary Insurance Holder Name:

DOB: //

SSN#:

Relationship to Patient:

Plan Name: Group:

Secondary Insurance:

Plan Name: Group:

DILATION
Dilation is required for a full health examination. Retinal tears or detachments may be missed if only a non-dilated exam is performed. Dilation side effects include light sensitivity and blurred vision for up to 6 hours

Please circle below
(Initials )

REFRACTION
Most medical insurance plans do not pay for the refractive part of an eye exam. If a refraction (part of exam that determines your need for glasses) is necessary during the exam. The patient will be responsible for the refraction charge.
(Initials )

CONTACT LENS FITTING
Contact Lens exams are different from a routine exam. They require a specialized fitting and have an additional fee. Most insurance plans will not cover a fitting for contact lenses. The patient will be responsible for the fitting at the time of the exam.
(Initials )

INSURANCE SIGNATURE ON FILE
I request that payment for authorized services be made directly to Dr. Michael K. Grofik, O.D. I authorize any holder of medical information about me to release to the healthcare financing administration and its agents any information needed to determine these benefits payable for related services
(Initials )

ACCOUNT RESPONSIBILITY
I acknowledge that insurance is a contract between the patient and the Insurance company. Any portion of your bill that is not covered by insurance is your responsibility. If you do not provide us with the correct insurance information, you will be responsible for any pended or denied charges. We do our best to notify all patients of our network status with each carrier presented; however, ultimately it is your responsibility to know the network/benefit or referral status prior to receiving services. Please note that delinquent accounts are referred to outside collection agencies when payment in full has not been received, financial assistance approved, or appropriate payment plans have not been arranged. These accounts are assessed interest.
(Initials )

HIPAA
I have read and understood the HIPAA Privacy Policy. A copy will be furnished upon request.v (Initials )

Signature: ) Date: //
IMPORTANT TESTING AUTHORIZATION

Our office believes that using the best technology possible is crucial to maintaining good ocular health and diagnosing to preventing ocular diseases. Our office utilizes a highly sophisticated digital retinal imaging system to provide a more thorough medical analysis of your eyes. This retinal imaging system takes photographs of the retina, interior blood vessels, and optic nerves. This procedure assists in the early detection of many disorders, including glaucoma, diabetic retinopathy, macular degeneration, retinal detachments, & other vision threatening conditions. The imaging also serves as a very important baseline, so every year your eyes can be compared to past images to monitor for even the smallest changes. Dr. Grofik strongly recommends retinal photos every 12months for every patient.

It is especially important for people who have
1. Headaches
2. Spots or flashes in vision
3. A family history of glaucoma, diabetes, or high blood pressure
4. High Cholesterol
5. Reached the age of 40
6. Never been in our office

There is an additional fee for this procedure of $24.00. If there is a diagnosis made, your insurance may help cover the cost. Please check the appropriate line below and sign at the bottom




Printed Name:

Signature:

Date: //


EYEWEAR LIFESTYLE QUESTIONNAIRE
Your eyewear is an investment in your personal apppearance. It's self expression. Your fashion statement without saying a word. An accessory to help you see better and live better. It's the first thing people see when they look you in the eye.

Occupation:

Currently wears glasses

Currently wears contacts

Your answer to these questions will guide us in recommending the best products to meet your eyewear needs.

What percentage of time do you wear your:
Glasses %
What percentage of time do you wear your:
Contacts %
What percentage of time do you wear your:
Sunglassss %

What do you like about your current glasses?

What do you dislike about your current glasses?

Do you experience light sensitivity/Glare

If you wear contact lenses please answer the following:

Rate comfort of: contact lens wear:

Contact vision :
How often do you discard your contact lenses?

How many hours/day do you wear contact lenses?

How many times a week do you sleep in your contact lenses?

Which of the following do you do regularly? (check all that apply)
Night driving
Work with small objects
Work on Computer: if yes how many hours a day Distance from screen IN. Work outdoors
Watch TV 3+ hrs/day
Read for long periods
Books or Tablet
Do you participate in any of the following?(check all that apply)
Golf
Fishing/Boating/Sailing
Raquet sports
Baseball/Softball
Basketball/Football
Sewing/Needlework
Playing a musical instrument
Other

Medical History

Height: Weight:

Eyes

Glasses or Contacts - Explain:  

Cataracts - Explain:   

Dry Eyes - Explain:   

Flashes / Floaters - Explain:   

Glaucoma - Explain:   

Loss of Vision - Explain:   

Surgery / Laser - Explain:   


Integumentary

Cancer - Explain:  

Eczema - Explain:  

Psoriasis - Explain:   


Neurological

Multiple Sclerosis - Explain:  

Alzheimer's - Explain:   

Epilepsy - Explain:

Other - Explain:   


Endocrine

Diabetes - Explain:   

Kidney Disease - Explain:   

Thyroid Problems - Explain:   

Other - Explain:   


Ear, Nose, Throat

Allergies - Explain:   

Chronic Cough - Explain:   

Other - Explain:   


Respiratory

Asthma - Explain:   

Chronic Bronchitis - Explain:   

Emphysema - Explain:   


Gastrointestinal

Acid Reflux - Explain:   

Other - Explain:   


Cardiovascular

High Cholesterol - Explain:   

Hypertension - Explain:   


Musculoskeletal

Arthritis - Explain:   

Osteoarthritis - Explain:   

Osteoporosis - Explain:   


Immunologic

HIV or Herpes - Explain:   


Psychiatric

Depression - Explain:   

Anxiety - Explain:   



Mark for any family member with any of the following (grandparents specify maternal or paternal):

Diabetes - Specify:   

Glaucoma - Specify:   

Hypertension - Specify:   

Cataracts - Specify:   

Macular Degeneration - Specify:   

Cancer - Specify:   



Social History
Alcohol Consumption:

Tobacco: if stopped, how long ago?

Recreational Drugs:


Medications:   

Allergies:   




(321) 253-9228
(321) 253-9446