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Seal Beach Eyes – Patient Registration Form
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2017-07-06T01:14:23+00:00
Seal Beach Eyes
Patient History
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4
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Patient Info
Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
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
Phone (Home)
Phone (Work)
Phone (Other/Cell)
Social Security Number
Date of Birth
MM slash DD slash YYYY
Age
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Other
Spouse's Name
First
Last
Employment
Full-Time
Part-Time
Other
Occupation
Company
Education
Full-Time
Part-Time
Other
Email
Medical History
Name of Family Doctor
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Date of Last Visit
MM slash DD slash YYYY
Please Select All That Apply
AIDS/HIV
Ear/Nose/Throat
Heart Disease
Asthma
Thyroid Condition
Kidney Disease
Stroke
Cancer
Headaches
Cigarettes/Tobacco
Alcohol
Pregnant
High Blood Pressure
Cataracts
Diabetes
Operations/Surgery
Other Health Problems
Type of Diabetes
Date of Surgery
MM slash DD slash YYYY
Please Explain Reason for Surgery
Please Explain Other Health Problems
Please List All Current Medications (Including Eye Drops)
Do You Have Any Allergies?
Yes
No
Please List All Alergies
Do You Have Any Medication Allergies?
Yes
No
Please List All Medication Alergies
Does any one in your family suffer from any of the conditions below? Please Select all that apply.
High Blood Pressure
Cataracts
Diabetes
Operations/Surgery
Other Health Problems
Retinal Detachment
Macular Degeneration
Glaucoma
Relationship to any with High Blood Pressure
Relationship to any with Cataracts
Relationship to any with Diabetes
Diabetes Type
Relationship to any with Operations/Surgery
Date of Surgery
MM slash DD slash YYYY
Please Explain Reason for Surgery
Relationship to any with Other Health Problems
Please Explain Other Health Problems
Relationship to any with Retinal Detachment
Relationship to any with Macular Degeneration
Relationship to any with Glaucoma
Personal Eye Information
Name of Previous Doctor
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Date of Last Exam
MM slash DD slash YYYY
Do You Wear Glasses?
Yes
No
Which options below best describe your glasses? Select all that apply.
Reading
Distance
Computer
Bifocals (Line)
Trifocals
Progressives (No-Line)
Do You Wear Contact Lenses?
Yes
No
How many hours per day do you wear your contacts?
Which best describes your contacts
Soft Lenses/Disposables
RGP
Conventional
Contact Lens Type/Brand
Contact Lens BC
Contact Lens DIA
Please select all that apply
Dry Eyes
Blurred Vision
Floaters or Spots
Double Vision
Itchy Eyes
Watering Eyes
Other Eye Condition(s)
Any Eye Operation
Any Eye Injury
Please Explain Other Eye Condition(s)
Date of Eye Operation
MM slash DD slash YYYY
Please Explain Reason for Any Eye Operation
Please Describe Any Eye Injury
Additional Information
Insurance
Vision Plan
ID#
Subscriber
Date of Birth
MM slash DD slash YYYY
Relationship to Subscriber
Self
Parent
Spouse
Medical Plan
ID#
Subscriber
Date of Birth
MM slash DD slash YYYY
Relationship to Subscriber
Self
Parent
Spouse
ASSIGNMENT AND RELEASE PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I hereby authorize this vision care provider to apply for benefits on my behalf for covered services rendered and request that all payments be made directly to the vision care provider. I agree to assume all responsibility of full charges whether or not paid by insurance. I further authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature
Date
MM slash DD slash YYYY
Health Insurance Portability and Accessibility Act – ACKNOWLEDGE OF NOTICE OF PRIVACY PRACTICE It is often necessary to use and disclose health information that identifies you in order to treat you, to obtain payment for our services, and, to conduct healthcare operations involving our office. The Notice of Privacy Practices describes these uses and disclosures in detail. Our office is in full compliant with HIPAA, and a copy of the Notice of Privacy Practice is available if you'd like a copy for your records.
Signature
Date
MM slash DD slash YYYY
How did you hear about our office?
Insurance List
Local Internet Search
Referral
Referred By:
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