Patient Registration Form

Patient Registration Form

PATIENT INFORMATION

Last Name


First Name


Middle Initial


Address


State / Zip


Telephone


Date of Birth


Email Address


Last Four Digits Of Social Security Number


Occupation (Grade in School)


Employer (School Name)


Family members seen at our practice:


Race


Preferred Language
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Ethnicity
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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?
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Do you currently wear corrective eyewear?


Do you currently wear corrective eyewear?


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 Concerns (Please Specify)


Please indicate the 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
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Do You or a Family Member Have Any of the Following Conditions?
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Systemic Health


High Blood Pressure


Diabetes


Heart Disease


Migraine/Headache
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Neurological Disorder


High Cholesterol
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Thyroid Disorder


Cancer
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Autoimmune Disorder


Psychiatric Disorder
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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

Vision Coverage


Name of Insurance Plan:


Vision Plan I.D. Number:


Primary Insured's Name:


Primary Insured's Date of Birth:


Vision Care Insured Last 4 Social Security Numbers:


Relationship to Insured:

Medical Insurance:


Name of Insurance Plan:


Insurance I.D. Number:


Group Number:


Primary Insured's Name:


Primary Insured's Date of Birth:


Relationship to Insured:


Medical Insurance Phone Number for Providers:
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Secondary Insurer (if any)


ID Number:
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​​​​​​​Secondary Medical Insurer

PLEASE BRING INSURANCE CARDS TO THE APPOINTMENT.

WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE
Doctor Recommendation:
Patient Recommendation
Insurance Plan Recommendation
Advertisement / Mailer
Internet
Location
AUTHORIZATION & NOTICE OF PRIVACY PRACTICES


Patient's or Authorized Person's Signature:
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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 the 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
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By signing/typing your name in 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.


Sign Here
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