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VISION NORTH: Updated Patient Form
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2019-03-27T17:10:32+00:00
VISION NORTH: Dr. Paul M. Cangiano and Dr. Cayla M Bergstrom Updated History Form
VISION NORTH: Patient History Update
Paperwork is an unavoidable part of the patient registration process. To expedite the process please complete as much of this form as possible and submit it at least 24 hours before your appointment. If you'd prefer to fill out the form in-office please arrive 10 minutes prior to your scheduled appointment. We thank you in advance for your time and look forward to meeting you!
Updated Information
Please let us know if there have been any changes in the following information:
Name Change
Yes
No
New Name
First
Last
Previous Name
First
Last
Address Change
Yes
No
New 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 Number Change
Yes
No
New Phone Number
Email Address Change
Yes
No
Email Address
Occupation/Grade
Vision Insurance Change
Yes
No
New Plan Name
New Subscriber ID
Primary Name and Date of Birth
Medical Insurance Change
Yes
No
New Plan Name
New Subscriber ID Number from Insurance Card
Primary Name and Date of Birth
Change in Your Health
Are you currently pregnant or nursing?
Yes
No - OR - Not Applicable
When did you last have your eyes examined?
< 1 year ago
> 1 year ago
If other, please specify
Do you wear contact lenses?
Yes, I wear contact lenses
No, I don't wear contact lenses
I don't wear contact lenses, but I would like to!
What brand of contacts do you wear?
Are you interested in hearing about Laser Vision Corrections (i.e. LASIK)?
Yes
No
Change in your current medications
Yes
No
This includes eye drops, vitamins and birth control
If yes, please specify which
Allergies to medications
Yes
No
What medications are you allergic to?
Are you a tobacco user?
Yes
No
Used to be a tobacco user
In a few words, describe the reason for your appointment
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