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Rockaway Registration Form
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2021-05-21T14:40:25+00:00
[1723] Rockaway Beach Optometry
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How did you hear about us?
Name (Last, First, Middle)
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Address Line 2
Preferred Language
Race
Communication Preference
Ethnicity
Phone
*
Date of Birth
*
MM slash DD slash YYYY
Sex
*
M
F
Last 4 of Social Security #
*
Email
*
Employment Status
Employer
Occupation
Marital Status:
Last Eye Exam Date
MM slash DD slash YYYY
Reason for visit:
*
If you wear glasses, then when specifically?
*
Always
Only while driving
For reading
Sunglasses
Computer
I don't wear glasses
If you wear contact lenses, then what type?
*
Disposable soft
Regular soft
Gas permeable
I don't wear contact lenses
If no, are you interested in contact lenses?
Yes
No
If you've ever had eye surgery, list the date and type
*
How many hours per day do you use a computer?
*
0-2
2-4
4-6
6-8
8+
Insurance Information
Medical Insurance: Primary
*
Member's Name
*
Date of Birth
*
MM slash DD slash YYYY
ID#
*
Secondary (If no seconday, type none)
*
Member's Name (If no secondary, type none)
*
Date of Birth (If no secondary, type none)
ID# (If no secondary, type none)
*
Vision Insurance: Primary
*
Member's Name
*
Date of Birth
*
MM slash DD slash YYYY
ID#
*
Secondary (If no secondary, type none)
*
Member's Name (If no secondary, type none)
*
Date of Birth (If no secondary, type none)
ID# (If no secondary, type none)
*
In case of emergency please contact:
Relationship to Patient
Phone
Referred by:
Financial Responsibility
I permit a copy of this authorization to be used in place of the original, and request payment of insurance benefits to ROCKAWAY BEACH OPTOMETRY. I understand and accept financial responisibility for all and any service rendered to me. I understand my insurance company is billed as a courtesy to me and payment of any bill is my responsibility. PARENT OR GUARDIAN SIGNATURE:
*
Date
*
MM slash DD slash YYYY
Notice of Privacy Practices:
A "Notice of Privacy Practices" that describes how my protected health information is used and disclosed has been made available to me. I understand I may request a printed copy at any time. PATIENT INITIALS:
*
Date
*
MM slash DD slash YYYY
Confidential Medical History & Review of Symptoms
Family History
Please answer the questions below regarding your immediate family (parents, grandparents, siblings, children)
Blindness/Vision Loss
*
Yes
No
If yes, which family member?
Crossed or "Lazy" eyes
*
Yes
No
If yes, which family member?
Cataracts
*
Yes
No
If yes, which family member?
Glaucoma
*
Yes
No
If yes, which family member?
Macular Degeneration
*
Yes
No
If yes, which family member?
Retinal Detachment
*
Yes
No
If yes, which family member?
Diabetes
*
Yes
No
If yes, which family member?
High blood pressure
*
Yes
No
If yes, which family member?
Heart disease
*
Yes
No
If yes, which family member?
Thyroid disease
*
Yes
No
If yes, which family member?
Cancer
*
Yes
No
If yes, which family member?
Lupus
*
Yes
No
If yes, which family member?
Other eye disease
*
Yes
No
If yes, which family member?
Do YOU currently have any problems in the following areas:
Blindness
*
Yes
No
Blurred Vision
*
Yes
No
Crossed or "lazy" eyes
*
Yes
No
Cataracts
*
Yes
No
Glaucoma
*
Yes
No
Macular degeneration
*
Yes
No
Retinal detachment
*
Yes
No
Eye trauma or injury
*
Yes
No
What type of injury/trauma and when?
*
Distorted vision/halos
*
Yes
No
Loss of side vision
*
Yes
No
Double vision
*
Yes
No
Dryness
*
Yes
No
Mucus discharge
*
Yes
No
Redness
*
Yes
No
Sandy or gritty feeling
*
Yes
No
Itching
*
Yes
No
Burning
*
Yes
No
Glare/light sensitivity
*
Yes
No
Eye pain or soreness
*
Yes
No
Flashes
*
Yes
No
Floaters
*
Yes
No
Fever/weight changes
*
Yes
No
Rosacea
*
Yes
No
Allergies/hayfever
*
Yes
No
Sinus congestion
*
Yes
No
Dry throat/mouth
*
Yes
No
Asthma
*
Yes
No
Emphysema
*
Yes
No
Chronic bronchitis
*
Yes
No
Diabetes
*
Yes
No
Vascular disease
*
Yes
No
High cholesterol
*
Yes
No
High blood pressure
*
Yes
No
Chronic diarrhea
*
Yes
No
Kidney/bladder
*
Yes
No
Rheumatoid arthritis
*
Yes
No
Anemia
*
Yes
No
Bleeding problems
*
Yes
No
Thyroid
*
Yes
No
Depression
*
Yes
No
Headaches (chronic)
*
Yes
No
Migraines
*
Yes
No
Seizures
*
Yes
No
History of STD:
*
None
Gonorrhea
Hepatitis
Syphilis
HIV
Other
If other, list below
Do you smoke?
*
Yes
No
Any alcohol or drug dependency?
*
Yes
No
List any medication allergies
*
List any medications you're taking
*
Signature
*
Date
*
MM slash DD slash YYYY
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