Skip to content
Patient Registration Forms Logo
Marciano Family OptometricBerenice2022-06-20T17:22:07+00:00

Marciano Family- West Palm

Patient Name
MM slash DD slash YYYY
Address
Gender
Marital Status
Ethnicity
Preferred Language
Preferred Contact Method
Race
Insurance Information
Medical Insurance
ID Number
Subscriber Name/DOB
 
Insurance Information
Vision Insurance
ID Number
Subscriber Name/DOB
 

NOTICE OF PRIVACY PRACTICES
I acknowledge that I have read and received a copy of Marciano Family Optometric’s Notice of Privacy Practices as required by HIPAA regulations.
MM slash DD slash YYYY
ASSIGNMENT AND RELEASE
I, the undersigned, certify that I have insurance coverage with the fore mentioned insurance and assign directly to Marciano Family Optometric all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am responsible for all co-pays and/or co-insurance. I also understand that if my insurance does not remit payment, I am responsible for any charges, whether paid or not paid by the insurance company. I, hereby, authorize the doctor to secure the payment of benefits and authorize the use of my signature on all insurance submissions.
MM slash DD slash YYYY

CONSENT FOR RELEASE OF MEDICAL INFORMATION(Required)
I agree to give my consent to Marciano Family Optometric to release medical conditions, test results, prescriptions, or medical records to the following individual(s). We will not honor disclosure of your medical information with anyone other than those stated without proper medical release forms on file.
Or, do not release information to anyone but myself
MM slash DD slash YYYY
Eye History
Date of Last Eye Exam:
Currently Wear Glasses:
Currently Wear Contacts: If so, How Many Hours a Day:
Reason for Today’s Visit:
 
Current Contact Lens Brand:
Right Eye Power:
Left Eye Power:

Have you or a family member, experienced, or been treated for, any of the following? Check all that apply.

Cataracts(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Cross Eye(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Glaucoma(Required)
Please list any family members who have experienced/were treated for the condition listed above.
LASIK or RP/PRK(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Lazy Eye(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Macular Degeneration(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Retinal Detachment(Required)
Please list any family members who have experienced/were treated for the condition listed above.

Are you currently experiencing, or have experienced, any of the following? Check all that apply.

Blurry Vision (Near)(Required)
Blurry Vision (Distance)(Required)
Burning(Required)
Discharge(Required)
Double Vision(Required)
Dryness(Required)
Excess Tearing / Watering(Required)
Eye Infection(Required)
Eye Pain or Soreness(Required)
Floaters or Spots(Required)
Halos(Required)
Headaches(Required)
Itching(Required)
Light Flashes(Required)
Light Sensitivity(Required)
Redness(Required)
Sandy or Gritty Feeling(Required)
Other(Required)
Medical History
Date of Last Physical Exam:
Primary Care Doctors Name:
Primary Care Doctors Number:
Pharmacy:
 
Have you or a family member, experienced, or been treated for, any of the following? Check all that apply.
AIDS/HIV(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Allergies(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Arthritis(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Asthma(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Blood/Lymph Disorder(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Cancer(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Diabetes(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Ears, Nose, Throat Conditions(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Gastrointestinal Conditions(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Heart Disease(Required)
Please list any family members who have experienced/were treated for the condition listed above.
High Blood Pressure(Required)
Please list any family members who have experienced/were treated for the condition listed above.
High Chloesterol(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Kidney Disease(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Lupus(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Neurological Conditions(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Psychiatric Disorder(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Seizures(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Skin Conditions(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Stroke(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Thyroid Dysfunction(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Other Medical Condition(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Current Medications:
Current Ocular Medications:

RETURN POLICY(Required)
No refunds will be made on professional services or procedures; including
comprehensive eye examinations, refractions, contact lens fitting fees, and medical office visits.
There are NO REFUNDS on customized prescription glasses, including frames and lenses. All lenses are customized for you and cannot be returned. If there is a doctor’s prescription change, within 60 days of purchase, lenses will be re-made at no cost to you. Any unopened/undamaged/unwritten on boxes of contact lenses can be exchanged within 60 days
of purchase if your prescription changes. Any exceptions to these policies may incur a
restocking fee of 10% U&C and must be approved by management.
Name
MM slash DD slash YYYY

To view our HIPPA policy please click here

Powered by 4PatientCare
Page load link
Go to Top