Please take the time to complete this list and bring it with you. There may be some things you cannot answer - no problem. Do the best you can. We appreciate your help.

1) Do you have a living will or a Durable Power of Attorney for healthcare? YES  or   NO

2) Bring all your medications with you, not just a list. Include any over the counter medications.

3) Bring a list of other health care providers you have seen in the past year, include any Specialists you have seen.

4) If you have been to see an eye doctor in the past year and can get a copy of your visit - please bring it. Otherwise the name and visit date will help.

Eye Doctor: _____________________________________________________________


Date Seen: ________________________________

5) Bring your insurance card and email address:

Email: _____________________________________________________________

6) Make a list of any medical concerns you would like to discuss: _________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

Advanced Directives-Living Will:

As part of your wellness visit your provider would like to discuss your living will with you. Of course, you may wish not to do this and that is perfectly fine. However, especially if you have Medicare, we are encouraging you to think about this. The main thing to think about is who you trust to make decisions for you in case you are incapacitated. Also the extent of care you wish to receive depending on your condition. While we are encouraging the discussion, it is a legal document. Once you know your wishes we encourage them to review them with your lawyer.

 
Testimonials

“Thank you Kim at Dresden Specialty Clinic, for helping me change the battery on my hearing aid even though I had never been seen at the clinic before.”

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