Skip to content
Search for:
Milton Family Eyecare
admin
2017-07-06T01:14:25+00:00
Milton Family Eyecare
Patient Registration Form
Today's Date
MM slash DD slash YYYY
Name
First
Last
Gender
Male
Female
Other
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
Work Phone
Cell Phone
Employer
Email
Martial Status
Single
Married
Divorced
Widowed
Seperated
Spouse's Name
First
Last
How did you hear about our office?
Friend
Dr. Referral
Relative
Insurance
Insurance Information
Vision Insurance
Medical Insurance
Primary Subscriber's Name
Relationship to Patient
Date of Birth
MM slash DD slash YYYY
Employer
Information for Minors
Please fill out this portion if you are under 18 years of age
Parent/Guardian's Name
First
Last
Date of Birth
MM slash DD slash YYYY
Authorization to Bill Insurance
I understand that my signature requests that payment be made and authorize release of medical information necessary to pay the claim. If other health insurance coverage is indicated in item 9 of the HCFA form or elsewhere on the approved claim forms or electronically submitted claims, my signature authorizes release of the information to the insurance of agency shown in my file. In Medicare assigned claims, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible co-insurance and non-covered services. Co-insurance and deductibles are based upon the charge determination of the Medicare carrier.
Patient's Signature
Date
MM slash DD slash YYYY
Notice of Privacy Acknowledement
In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for your services, and to conduct healthcare operations involving our office. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. I acknowledge that I have received the Notice of Privacy Practices from Irish Eyes.
Patient's Signature
Date
MM slash DD slash YYYY
If signing as a personal representative, describe relationship to the patient and the source of authority to sign this form:
Medical History Questionnaire
Name
First
Last
Today's Date
MM slash DD slash YYYY
Primary Care Physician
Primary Care Physician Phone Number
How many years ago was your last eye examination?
Where was your last eye examination?
Do you currently wear glasses?
Yes
No
How old are your glasses?
Do you currently wear contacts?
Yes
No
Are you interested in being bitted with contacts?
Yes
No
Do you currently, or have you ever experienced any following problems:
Blurred / Distorted vision
Yes
No
Double Vision
Yes
No
Blackout or Temporally loss of vision
Yes
No
Severe or Frequent headaches
Yes
No
Itching / Burning / Stinging eye
Yes
No
Sandy / Gritty / Foreign body sensations
Yes
No
Flashes of light and/or Floaters
Yes
No
Eye infection
Yes
No
If yes, what?
Eye Injury
Yes
No
If yes, what?
Cataract
Yes
No
If yes, surgery?
Any other problems:
Social History
Do you Smoke?
Yes
No
How many packs do you smoke a day?
Do you drink Alcohol?
Yes
No
How many drinks a day?
Do you use a computer?
Yes
No
How many hours a day do you use a computer?
Hobbies
Medical History
List any medications (including oral contraceptives, aspirin, and other over the counter medication):
List any allergies to any medications:
Do you or any of your blood relatives have any of the following health problems in the following areas:
Diabetes
No
Self
Family
Relationship
High Blood Pressure
No
Self
Family
Relationship
Heart Disease
No
Self
Family
Relationship
Cancer
No
Self
Family
Relationship
Lupus
No
Self
Family
Relationship
Arthritis
No
Self
Family
Relationship
Thyroid disease
No
Self
Family
Relationship
Glaucoma
No
Self
Family
Relationship
Lazy, Crossed eye
No
Self
Family
Relationship
Macular Degeneration
No
Self
Family
Relationship
Blindness
No
Self
Family
Relationship
Weight Loss/Gain
No
Self
If yes, please explain
Lung Problem
No
Self
If yes, please explain
Allergy
No
Self
If yes, please explain
Neurological
No
Self
If yes, please explain
Psychological
No
Self
If yes, please explain
Other
Go to Top
