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Freestone Optometric Center New Patient Registration
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2018-04-02T19:05:14+00:00
Freestone Optometric Center New Patient Registration
Today's Date
*
MM slash DD slash YYYY
Name
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First
Last
Birthdate
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MM slash DD slash YYYY
Patient Social Security Number
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Email
*
Marital Status
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Single
Married
Divorced
Widow/Widower
Address
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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
Home Phone
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Cell Phone
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Business Phone
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Name of Parent or Spouse
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First
Last
Occupation
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Employer
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Type of Insurance
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None
VSP
MES
Medi-cal
Medicare
Other
If "Other" please specify:
Method of Payment
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Cash
Check
Credit Card
Member Name
First
Last
Member DOB
MM slash DD slash YYYY
Member Number
Emergency Contact Name
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First
Last
Relationship
Emergency Phone:
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How Did You Find Out About Our Office
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Insurance Company
Drive-by
Patient
Internet
Phonebook
List All Medications You Are Taking
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Medication Allergies
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List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries
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Do You Use Tobacco Products?
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Current
Previous
Never
Do You Drink Alcohol?
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Socially
Daily
Never
Do You Use Recreational Drugs?
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Socially
Daily
Never
Patient Eye Health
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Amblyopia (lazy eye)
Blurred Vision-Far
Blurred Vision-Near
Burning Eyes
Cataracts
Double Vision
Drooping Eyelid
Dry Eyes
Eye Turn
Floaters/Spots
Fluctuating Vision
Foreign Body Sensation
Glaucoma
Glare/Light Sensitivity
Headaches
Itchy Feeling
Infection of Eye/ Lid
Loss of Vision-Central
Loss Of Vision-Side
Mucus/Discharge
Redness
Retinal Detachment
Tearing/Watery Eyes
None of the Above
Patient Cardiovascular Health
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Vascular Disease
Hypertension
Diabetes
Heart Pain
None of the Above
Ear/Nose/Throat
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Ear Infection
Sore Throat
Sinus Problems
Congestion
Allergies/Hayfever
Loss of Hearing
None of the Above
Are you interested in:
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Glasses
Contact Lenses
Refractive Surgery
Sunglasses
Back-up Glasses
Computer Glasses
Hobbies:
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Golf
Fishing
Raquetball/Tennis
Basketball
Sewing
Water Sports
Skiing
Piano
Other
Hobbies: Other:
Would you like to know more about:
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No-line bifocals
Photo-sensitive lenses
Light-weight, thin lenses
Shatter-resistant lenses
Scratch-resistant lenses
Anti-glare lenses
Ultra-violet protection
Designer frames
Lightweight frames
Disposable contact lenses
Colored contacts
Monovision contacts
Contact lenses for astigmatism
Contact lenses for dry eyes
I authorize the release of any medical or other information necessary to process my insurance claim. I also authorize payment of benefits to Gary M. Freestone O.D.. I understand that I will be financially responsible for payment of all charges, co-payments, and deductibles incurred for services rendered from his office, that may not be covered by my insurance provider. I also understand that delinquent accounts will be sent to collections.
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Yes
No
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