Patient Registration Form

Patient Registration Form

Patient Registration Form

Patient Registration Form

PATIENT INFORMATION
Last Name:
First Name:
Middle Initial:
Street / City
State / Zip
Telephone
Date of Birth:
Occupation (Grade in School)
Employer (School Name)
Family members seen at our practice:
Race
Preferred Language
Ethnicity
RESPONSIBLE PARTY (if different from above)
Last Name:
First Name:
Middle Initial:
Street / City
State / Zip
Telephone
Date of Birth:
Relationship to Insured
MEDICAL HISTORY
PRIMARY CARE PHYSICIAN
PCP PHONE NUMBER
DATE OF LAST PHYSICAL
Do you use tobacco products?
Do you drink alcohol?
Do you use recreational drugs?
Women: Pregnant/Nursing?
Do you currently wear corrective eyewear?
If Yes, please check all that apply:
If using contact lenses, what brand(s) are you using?
How often do you replace your contacts and what type of solution do you use to clean and store your contacts?
Approximately when was your last eye exam?
Doctors Name:
City, State, Phone:
MEDICAL CONCERN (Please Specify)
OTHER VISION CONCERN (Please Specify)
Please indicate medications you're currently taking:
Please indicate if you have any allergies to medicines
DO YOU OR A FAMILY MEMBER HAVE ANY OF THE FOLLOWING CONDITIONS?
Eye Health
DO YOU OR A FAMILY MEMBER HAVE ANY OF THE FOLLOWING CONDITIONS?
Systemic Health
Number of hours working on a computer
Are you bothered by glare in the office/workplace?
Please list any hobbies, activities, or sports you enjoy
INSURANCE / VISION CARE COVERAGE
Name of Insurance:
ID No.:
Subscriber Name:
Group Number:
Relationship:
Last 4 Digits of SSN:
Secondary Insurer (if any)
Group Number:
ID No.:
Last 4 Digits of SSN:
WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE
Name:
Name:
Name:
May we contact you by e-mail? note: information will not be shared with any outside parties
AUTHORIZATION & NOTICE OF PRIVACY PRACTICES
RETINAL IMAGING

We have incorporated a highly sophisticated retinal imaging camera into our practice. The retinal camera can detect early retinal pathology that is often associated with many common ocular diseases. This technology can help identify diseases such as early glaucoma, diabetic retinopathy, macular degeneration, tumors, and vascular problems. The test would provide the optometrist with important baseline diagnostic information, and give a permanent photographic record of your retina for future comparison.

We recommend that all of our patients over the age of 10 receive this test. It is especially important for those patients who have a history of diabetes, high blood pressure, high cholesterol, or headaches. It is highly recommended if you have a strong prescription or if you have any family history of glaucoma or macular degeneration.

This state of the art procedure requires an additional 5 minutes of your time. The fee for this test is $35.00. Insurance or vision benefits do not generally cover this testing. However, if we pick up an abnormality and recommend further testing, insurance may cover the additional fees.

Please check the appropriate box below:

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE:

I authorize the release of any medical or other information necessary to process insurance claims. I also request payment of benefits either to myself or to the party who accepts assignment. I understand that I am responsible for any balance due for services and/or products that are deemed "not covered" or denied or delayed (over 60 days) by my benefit plan.

NOTICE OF PRIVACY PRACTICES

By signing/typing your name on the field below, you have read, understand, and acknowledge that you have received a copy of the Federal Hill Eye Care Notice of Privacy Practices.

RELATIONSHIP TO PATIENT IF OTHER THAN SELF: