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Rocky Mount Family Eye Care
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2017-07-06T01:14:20+00:00
Rocky Mount Family Eye Care
Rocky Mount Family Eye Care Registration & Medical History
We require payment in full/or insurance co-pays at the time services are rendered or eyewear is to be ordered. An insurance card must be presented at your visit to ensure proper billing.
Date
MM slash DD slash YYYY
Birthdate
MM slash DD slash YYYY
Email
Name
First
Middle
Last
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
Sex
Male
Female
Social Security Number
Employer
Work Phone
Home Phone
Marital Status
Spouse's Name & Employer
Emergency Contact Person - name & phone number
Chief Complaint
Do you have vision insurance?
Yes
No
Do you have health insurance?
Yes
No
Name of insurance company
Policy holder
Relationship to policy holder
Policy holder's SSN and DOB
Please bring both your vision and health insurance cards to your appointment.
*
Co-pays & deductibles are required on the date of service. We will bill your insurance but can't assure payment. You are fully responsible for payment. (Please give your insurance forms or cards to the front desk)
*Professional fees are due at the time services are rendered. I will be responsible for charges to my family or me. Patients are responsible for all costs associated with collection or legal actions, including 33 1/3% attorney fees.
Initial:
*Any materials not picked up within 90 days of notification will be returned to stock or donated. All monies paid will be forfeited.
*
Initial:
Who is your family physician?
Physician's city/location
List any medication or eye drops you are allergic to
List any medication you are taking now -
perscription or over-the-counter
List all major injuries, surgeries and/or hospitalizations you have had
Do you wear glasses?
Yes
No
Do you wear contacts?
Yes
No
If yes, how old is your present pair of lenses?
Type of contact lenses
Rigid
Soft
Extended Wear
Other:
Are they comfortable?
Yes
No
Do you drive?
Yes
No
If yes, do you have visual difficulty when driving?
Yes
No
If yes, please describe
Do you use tobacco products?
Yes
No
If yes, type/amount/how long?
Do you drink alcohol?
Yes
No
If yes, type/amount/how long?
Do you use illegal drugs?
Yes
No
If yes, type/amount/how long?
Have you ever been exposed to or infected with Gonorrhea?
Yes
No
Have you ever been exposed to or infected with Syphilis?
Yes
No
Have you ever been exposed to or infected with HIV?
Yes
No
Have you ever been exposed to or infected with Hepatitis?
Yes
No
Acknowledgement
If insurance is filed on my behalf, I authorize my insurance benefits to be paid directly to Kartesz Family Eyecare Center.
Initial:
I authorize the release of medical information to insurance carriers or other physicians if it is deemed necessary by any optometrist for financial or consultative purpose. Initial:
I authorize the release of medical information to insurance carriers or other physicians if it is deemed necessary by any optometrist for financial or consultative purpose.
Initial:
Signature
Date
MM slash DD slash YYYY
Responsible Party (Parent/Guardian of Minors)
Name
Birthdate
MM slash DD slash YYYY
SS#
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
Review of Systems
Do you currently, or have you ever had any problems in the following areas: (If YES, please explain and list medications)
INTEGUMENTARY (Skin)
No
Yes
?
Explain/Medications
NEUROLOGIC
Headaches
No
Yes
?
Migraines
No
Yes
?
Seizures
No
Yes
?
Explain/Medications
Eyes
Loss of Vision
No
Yes
?
Blurred Vision
No
Yes
?
Distorted Vision/Halos
No
Yes
?
Loss of Side Vision
No
Yes
?
Double Vision
No
Yes
?
Dryness
No
Yes
?
Mucous Discharge
No
Yes
?
Redness
No
Yes
?
Sandy or Gritty Feeling
No
Yes
?
Itching
No
Yes
?
Burning
No
Yes
?
Foreign Body Sensation
No
Yes
?
Excess Tearing/Watering
No
Yes
?
Glare/Light Sensitivity
No
Yes
?
Eye Pain or Soreness
No
Yes
?
Chronic Infection of Eye or lid
No
Yes
?
Sties or Chalazion
No
Yes
?
Flashes/Floaters in Vision
No
Yes
?
Tired Eyes
No
Yes
?
Explain/Medications
EARS, NOSE, MOUTH, THROAT
Allergies
No
Yes
?
Hay Fever
No
Yes
?
Sinus Congestion
No
Yes
?
Runny Nose
No
Yes
?
Post-Nasal Drip
No
Yes
?
Chronic Cough
No
Yes
?
Dry Throat/Mouth
No
Yes
?
Explain/Medications
RESPIRATORY
Asthma
No
Yes
?
Chronic Bronchitis
No
Yes
?
Emphysema
No
Yes
?
Explain/Medications
VASCULAR
Diabetes
No
Yes
?
Heart Pain
No
Yes
?
High Blood Pressure
No
Yes
?
Vascular Disease
No
Yes
?
Explain/Medications
GENITOURINARY
Genitals/Kidney/Bladder
No
Yes
?
Explain/Medications
BONES/JOINTS/MUSCLES
Rheumatoid Arthritis
No
Yes
?
Muscle Pain
No
Yes
?
Joint Pain
No
Yes
?
Explain/Medications
LYMPHATIC/HEMATOLOGIC
Anemia
No
Yes
?
Bleeding Problems
No
Yes
?
Explain/Medications
ENDOCRINE
Thyroid/Other Glands
No
Yes
?
Explain/Medications
PSYCHIATRIC
No
Yes
?
Explain/Medications
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