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4081 Superior Vision Registration
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2019-11-11T14:07:24+00:00
4081 Superior Vision Registration Form
Welcome to Superior Vision
Today's Date
MM slash DD slash YYYY
Name
First
Middle Initial
Last
Home Phone
Cell Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
SSN
Age
Date of Birth
MM slash DD slash YYYY
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Other
Race
Occupation
Email
Would you like to receive TEXT message confirmations?
Yes
No
How did you hear about us?
What is the name and number ofyour Primary Care Physician?
Guardian
Primarv lnsurance: Please Select (Vision or Medicall
Vision
Medical
Subscriber's Name
SSN
DOB
MM slash DD slash YYYY
Relationship to Patient
Phone
Address (if different from patient)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Insurance Company
ID#
Group#
Pharmacy Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Questions
What's the main reason for your visit today?
Exam
Glasses
Contacts
Have you worn?
Eyeglasses
Contacts
Have you ever had LASIK?
Yes
No
If yes, when:
When was your last eye exam?
Do you smoke?
Yes
No
How long?
How many packs a day?
Do you have allergies?
Yes
No
Seasonal?
Yes
No
Other
EYE AND GENERAL HEALTH HISTORY
Please select all that apply
Asthma, Bronchitis, Emphysema
Kidney Disease
Tuberculosis
Diabetes
lnsulin
Migraines
Psychiatric Disorder
Any Nervous Disorder
Heart Attack or Heart Failure
Chest Pain
Congestive Heart Failure
Ulcer, Heartburn
Thyroid Disorder
Sickle Cell Anemia
Head or Spinal lnjuries
Seizures, Convulsions, Fainting
Stroke
Permanent Defect from lllness, Disease, or lnjury
Pregnant
High Blood Pressure
HlV/AIDs
Suffering from other Disease
Other Diagnosed Health Problems
Arthritis
Cancer
Lymphoma
If diabetes, # of years
If insulin, # of years
If cancer, type:
Please check all surgeries vou have had:
Tonsillectomy
Heart By-Pass
Hysterectomy
C-section
Stint
Gall Bladder
Knee
Hip
Mastectomy
Appendectomy
Mole Removal
Plastic Surgery
Endoscopy
Back
Transplant
Dental Surgery
Hernia Repair
Other surgeries (Please list)
Dates of surgeries
Please list all medications you are currently taking:
Please List Medications you are ALLERGIC to:
Ocular History (Have you been diagnosed with any of the following in the Past?l
Cataracts
Retina Disease
Glaucoma
Crossed Eyes
lritis (red inflamed eye)
Cornea Disease(front surface of Eye)
Injury
Other Eye Disorder
Cataracts (Date of Surgery) Right Eye
Cataracts (Date of Surgery) Left Eye
Do you have a lens implant?
Yes
No
Retina Surgery (Date of Surgery) Right Eye
Retina Surgery (Date of Surgery) Left Eye
Explanation of Eye lnjury
Family History (Blood Relatives only: Mark Relation, i.e. Mother, Father, Grandparent' Aunt)
Glaucoma
Cataracts
Cornea Disease
Macular Degeneration
Retinitis Pigmentosa
Blindness
Cancer
Diabetes IDDM/TYPE ll
Heart Attack
Diabetic Retinopathy
Retinal Detachment
Stroke
Tuberculosis
High Blood Pressure
Other General Medical Problems:
Loss of vision
Yes
No
Floaters
Yes
No
Eye pain
Yes
No
Burning
Yes
No
Blurred or Distorted Vision
Yes
No
Flashes of Light
Yes
No
Loss of Side Vision
Yes
No
Glare/ Sensitivity to light
Yes
No
Do you have problems with night vision?
Yes
No
Financial Policy
A clear understanding of our Financial Policy is an important part of our professional relationship. We are pleased to discuss the financial aspects of your care. Feel free to ask questions regarding your fees, financial responsibilities, insurance coverage, or the Financial Policy. All patients must complete the "New Patient" forms before seeing the Doctor. The following forms of payment are accepted: Cash, Personal Checks, Debit Cards, Care Credit, Health Savings Cards, VISA, MASTERCARD, AMERICAN EXPRESS, and DISCOVER.
INSURANCE
Each insurance plan is different and it is YOUR responsibility to check with your insurance company regarding coverage prior to your appointment. Please remember too that we file the insurance as a courtesy for you, and we will attempt to collect on all claims. Failure to pay by the insurance company for any reason will result in the bill becoming your responsibility. Insurance is a contract between you and your insurance company. Our office will NOT become involved in disputes between you and your insurance regarding deductibles, co-payments, covered charges, or secondary insurance other than to provide information regarding the services provided by our practice. We will file with most insurances: however, we are not contracted with SPECTERA at this time. When a doctor contracts with an insurance company, the doctor is considered "in network". The insurance company has specific payment schedules for both "in network" and "out of network" providers. For example, a plan that pays 80% for an "in network" provider may only cover 60% for an "out of network" provider. You will be responsible for the portion that is not covered by your insurance.
MEDICAID
We do cunently accept Medicaid. providing that you are eligible for that date of service. If you are NOT eligible, the charges for that day will be your responsibility and you will be required to pay the bill. Sometimes, the Medicaid eligibility slip shows that the patient has a primary insurance. Medicaid is always regarded as secondary insurance and will NOT pay until the insurances outlines on the slip have been billed. We understand that sometimes theses primary insurances are outdated, but we have no choice but to file with them. You are responsible for providing us with this primary insurance information. If you care to dispute the insurances, you will need to contact your caseworker.
RELEASE OF OPTICAL INFORMATION
Signature
I hereby give permission to release my optical information (for purpose of collection of my optical bill) by means of electronic submission, mail, far, or phone I hereby give permission to contact me via phone, answering machine, and/postcard to remind me of my optical appointments or need for optical re-care
PAST DUE ACCOUNTS
If it becomes necessary for our office to use a collection agency or legal representation to collect a seriously past due account, you will be liable for any fees incurred during the collection process. If you have any questions or concerns, please let us know.
Patient Name
First
Last
Responsible Party
Responsible Party Signature
I have read and understand the financial policy and agree to the terms as stated above.
Retinal images are an essential part of your annual comprehensive eye exam.
Optomap: When reviewed, the scan becomes a permanent part of your medical record, enabling the doctor to make an important comparison should potential vision-threatening conditions show themselves at a future examination. Retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments, diabetic retinopathy, and many systemic diseases can now be seen without dilation* for most patients. The doctors at Superior Vision highly recommend Optomap imaging for all patients on an annual basis. Optomap imaging allows the doctor to compare ocular health changes and early detection of many ocular diseases
Please check ONE of the following:
I understand and accept the Optomap retinal imaging ($35 copay). ln MOST cases, dilation is not necessary if retinal imaging is performed.
I prefer Dilation today (no copay): Please allot an additional 20 minutes for your examination to allow the eyedrops to become effective. Side effects of dilation include light sensitivity and blurry vision.
I have read and understand this document:
Signature
Date
MM slash DD slash YYYY
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