Simpson and Mann Infant Registration

Date of Exam

Name

First Middle Last Nickname

Gender

Date of birth

Age

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Social Security #

Mother's Name

First Last

Mother's occupation

Mother's work phone

Mother's Social Security #

Father's Name

First Last

Father's Occupation

Father's work phone

Father's Social Security #

Names and ages of family members living at home

Referred by

Physician's Name

First Last

Physicians's Phone

Vision Insurance

If other, what vision insurance do you have?

Insured by

Major medical insurance

If other, what medical insurance do you have?

Insured by

Main reason for exam

My child is

Length of pregnancy

During pregnancy of this child, which, if any of the following occurred:

Toxemia
Smoking
Little Obstetrical Care
Injury by Fall
Prescribed Medication
Severe Illness
Trauma
Use of drugs
Use of alcohol

Additional explanation of pregnancy:

Type of Delivery:

Were there any problems during delivery?

What problems during the delivery?

Child's Birth Weight

Is your child currently taking any medication?

List medications and purpose

Does your child have a history of:

High fever
Ear infections
Epilepsy or seizures
Medication allergies
Allergies

Has child had any of the following?

Glasses
Patching
Vision therapy
Eye surgery

Additional Eye History Info?

Has any blood relative had:

Developmental Stages:

Eye control 180 degrees - average age 3 months

Head control - average age 3 months

Hand grasp - average age 4 months

Sits without support- average age 6.5 months

Walks unaided- average age 12 months

Scribbles Spontaneously- average age 15 months

Combines 2 Different Words- average age 21 months

Copies Circle- average age 3 years

Rides Tricycle- average age 3 years

Knows Colors- average age 4 years

List all previous evaluations done on your child

Doctor or Institution	Date	Type of Evaluation	Results/Treatment/Intervention

Individuals or agencies that you wish to receive the results of our exam

Name	Address

Further comments?

PAYMENT TERMS: We are happy to assist you in the filing of your insurance claim. If your insurance will not pay the anticipated amount, or your insurance pays you directly, we ask that you pay the balance. Office policy calls for payment at the time of service. If eyewear or contact lenses are to be ordered, a minimum 50% deposit is requested and the balance is due upon delivery. We accept cash, personal checks, Visa and Mastercard. A monthly rebilling fee of $5 is added to all accounts with unpaid balances after 30 days. I have read and agree to all the provisions of the office financial policy I have received/reviewed a copy of the health care information privacy policy for Simpson and Mann Optometry

Relation to child

Signature

Date

Simpson and Mann Infant and Preschool Registration