Wada Optometry Patient Registration

Today's Date
MM slash DD slash YYYY
Name*
First Middle Last
Sex
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Age
Social Security Number

XXX-XX-XXXX
Primary Phone Number*
Would you like to receive text reminders?
- Yes
- No
Email*
How did you hear about us?
Primary purpose of today's visit:
Language:
Employer
Occupation
Insurance Information
Vision Insurance*
ID Number*
Subscriber's Name
First Last
Plan Number
Subscriber's Birth Date
MM slash DD slash YYYY
Patient's Relationship to Subscriber
- Self
- Spouse
- Child
- Other
Other: Please Specify
Medical Insurance Information
Medical Insurance
ID Number
Subscriber's Name
First Last
Plan Number
Subscriber's Birth Date
MM slash DD slash YYYY
Subscriber's SSN
Patient's Relationship to Subscriber
- Self
- Spouse
- Child
- Other
Other: Please Specify
Last Eye Exam:
MM slash DD slash YYYY
Doctor/City:
Last Physical Exam
MM slash DD slash YYYY
Doctor/City:
Medical History
With or without glasses/contacts, do you frequently have any of the following symptoms?
- Blurry Distance
- Blurry Close
- Red Eyes
- Dizziness
- Squinting
- Itchy Eyes
- Discharge from eyes
- Double Vision
- Light Sensitive
- Night Vision Problem
- Excessive Tearing
- Headaches
- Discharge from Eyes
- Dry Eye
- Sleepiness when reading
Do you have any of the following?
- Allergies
- Anxiety
- Arthritis
- Asthma
- Auto Immune Disease
- Cancer
- Depression
- Diabetes
- Elevated Cholesterol
- Head Trauma
- Heart Disease
- Hypertension
- Multiple Sclerosis
- Stroke
- Thyroid Conditions
- Other
If other, please specify:
Do any family members have any of the following?
- Allergies
- Anxiety
- Arthritis
- Asthma
- Auto Immune Disease
- Cancer
- Depression
- Diabetes
- Elevated Cholesterol
- Head Trauma
- Heart Disease
- Hypertension
- Multiple Sclerosis
- Stroke
- Thyroid Conditions
- Other
If other, please specify:
Patient Eye History. Select all that apply
- Amblyopia (lazy eye)
- Blindness
- Cataracts
- Color Deficiency
- Eye Injury
- Eye Surgery
- Glaucoma
- Macular Degeneration
- Retinal Detachment
- Strabismus (eye turn)
Do any family members have any of the following? Check all that apply
- Amblyopia (lazy eye)
- Blindness
- Cataracts
- Color Deficiency
- Eye Injury
- Eye Surgery
- Glaucoma
- Macular Degeneration
- Retinal Detachment
- Strabismus (eye turn)
If you have marked any of the above, please explain (When/Medication/Controlled/Etc):
We recognize that your eyes are very important to you. We would like to know how you use your eyes on a daily basis. Along with your eye exam, this info will assist us in recommending the best options for your eyes and your lifestyle.
Do you wear glasses currently?
- No
- Yes
If yes:
- Full-time
- Part-time
- Distance Only
- Reading Only
- Computer
Check all that apply
Do you wear contacts?
- No
- Yes
Are you interested in contacts?
- Yes
- No
What type do you wear?
Would you like to discuss laser refractive surgery options today?
- Yes
- No
Which of the following do you do on a regular basis (check all that apply):
- Read for long period
- Drive - Nighttime
- Work under fluorescent light
- Photography
- Watch TV
- Drive - Daytime
- Weld/Woodwork
- Bike/Hike/Jog
- Work outdoors
- Use IPAD/Tablet
- Paperwork/writing
- Work w/ small objects
- Paint/Draw
- Use Computer
- Travel on airplanes
- Other
If other, please specify:
List all sports and hobbies you participate in:
Do your eyes experience any of the following symptoms? (Check all that apply)
- Sensitive to light
- Floaters/Flashes
- Red Eyes
- Eye turn in/out
- Painful or sore eyes
- Itchy Eyes
- Feel gritty
- Dry Eyes
- Double Vision
- Other
If other, please specify:
Are you interested in any of the following options for your new eyeglasses? (Check all that apply)
- Light weight lens
- No-line Bifocals
- Thinner lens
- Scratch Resistant Coating
- Transitions
- Anti-glare coating
- Prescription Sunglasses
- Other
If other, please specify
Privacy Policy

The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provider a standard for certain health information about the patient to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment, or healthcare operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may be to disclose personal health information for purpose of treatment, payment, or healthcare operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use of disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your PErsonal Health Information (PHI). IF you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.

You have the right to review our privacy note, to request restrictions and revoke consent in writing after you have reviewed our privacy note.

Print Patient's Name

First Last

Signature of Patient or Guardian

Date

Insurance Information

Medical Insurance Information

Medical History

Privacy Policy