Patient Registration Form

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

Ethnicity

PRIMARY CARE PHYSICIAN

PCP PHONE NUMBER

DATE OF LAST PHYSICAL

Do you use tobacco products?

YesNo

Do you drink alcohol?

YesNo

Do you use recreational drugs?

YesNo

Women: Pregnant/Nursing?

YesNo

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

Number of hours working on a computer

Are you bothered by glare in the office/workplace?

YesNo

Please list any hobbies, activities, or sports you enjoy

Vision Care 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:

Doctor Recommendation:

Name:

Patient Recommendation:

Name:

Insurance Plan Recommendation:

Name:

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May we contact you by e-mail? note: information will not be shared with any outside parties

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:

I would like to have the Retinal Imaging test performed.I decline the Retinal Imaging test at this time

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.

I agree

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 .

I agree

RELATIONSHIP TO PATIENT IF OTHER THAN SELF: