Simpson and Mann Optometry Adult Registration

Today's Date

Name

First Last

Date of Birth

Address

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

Home Phone

Cell Phone

Social Security Number

Driver's License Number

Employer

Work Phone

Person responsible for account

First Last

Date of Last Eye Exam

Have you ever had vision therapy?

Have you ever worn glasses?

Do you wear glasses now?

Why do you wear glasses?

Do you wear contacts now?

What contacts do you wear?

Have you had problems wearing contacts?

What problems have you had wearing contacts?

Have you been told you cannot wear contacts?

Are you interested in trying contacts?

Health History

Check all that apply to you

Health History

Check all that run in your family

Are you currently under a physician's care?

Doctor's Name

First Last

Date of last physical exam

Are you regularly taking medications?

For what conditions?

How is your general health?

What kind of work do you do?

What activities do you do at work?

What other activities do you do at work?

Do you use a computer at work?

Do you use a computer at home?

How many hours do you spend on the computer daily?

What lenses do you use while on the computer?

When computing, do your eyes get

Do you feel pain or discomfort in you

Neck
Back
Shoulders
None

Do letters ever seem to "swim"?

Does office lighting ever bother you?

Do reflections and glare bother you?

Do you experience any of the following at work or at home?

In what recreational activities do you participate?

What other recreational activities?

Do you wear any special or protective eyewear for your sport?

Does your vision, or do you lenses, interfere with any activities?

What are you doing to protect your eyes from ultraviolet exposure?

Do you currently wear glasses that have an anti-reflective coating?

Is television viewing ever uncomfortable?

Describe discomfort

Do you recline while viewing television?

Do your lenses work for TV?

Do you often play video games?

Hours spent playing video games daily

Are you a new patient?

How did you hear about us?

Who referred you?

Where online did you hear about us?

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

Signature

Date

Simpson and Mann Adult Registration Form