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You and Eye Dr Kristy Bhend Patient Registration Form
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2019-02-07T22:39:46+00:00
You and Eye - Dr. Kristy Bhend Registration Form
Welcome to our office--
It is our true pleasure to have you here today. We strive to offer patient-centered eye and vision care. Please complete the following to help us get to know you and tailor your exam to your exact needs.
Patient Information
Have you had fever, cough, sore throat, nausea, vomiting, shortness of breath or loss of taste and smell in the past 14 days?
*
Yes
No
Have you been exposed to someone with the flu or coronavirus in the last 14 days?
*
Yes
No
Myself, and/or someone living in my immediate household has traveled outside the state within the past 14 days.
*
Yes
No
If YES to either of the above 3 questions, for the safety of our patients, staff and visitors we ask that you reschedule your exam.
By signing this form, I agree that I will not hold You and Eye Family Eye Care or any of its doctor’s or staff personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge You and Eye Family Eye Care and its doctor’s and staff for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.
*
Today's Date
*
MM slash DD slash YYYY
Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Sex
Male
Female
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
Cell Phone
*
Home Phone
Work Phone
Email
*
Guardian Name (if applicable)
Preferred Method of Contact
Home Phone
Cell Phone
Text Message
Email
Occupation (or Grade)
Employer (or School)
Insurance Information
Subscriber's Name (if different from above)
First
Last
Subscriber's Date of Birth
MM slash DD slash YYYY
Please select your medical insurance
*
Medica
BCBS
Medicare
Preferred One
Health Partners - Out of Network
U-Care - Out of Network
Humana - Out of Network
United Healthcare - Out of Network
None / Plan to self-pay for visit
Member/Policy ID
*
Group ID
*
What is your Vision Insurance?
*
Davis/Superior (out of network)
Spectera
Avesis
Eyemed (out of network)
VSP
Other
None / Plan to self-pay for visit or use medical insurance
Subscriber ID/Policy ID
*
For VSP patients, this is subscriber's last 4 digits of SSN
Group ID
*
Do you have any additional supplemental insurance?
*
Yes
No
BCBS
Humana - Out of Network
Other Insurance information notes
Ocular History
Do You Wear Glasses?
*
Yes
No
If yes, how old are your present glasses?
Do You Wear Contacts?
*
Yes
No
If yes, what type?
RGP
Soft
Other
If soft, what brand?
Have you had refractive surgery?
Yes
No
If yes, what date and type?
Do you use a computer?
Yes
No
If yes, how many hours per day?
Are you currently experiencing any of the following problems with your eyes? Check the box if yes.
Blurred Vision
Loss of Vision
Loss of Side Vision
Distorted Vision
Tired Eyes
Flashes
Floaters in Vision
Halos/Glare/Light Sensitivity
Dryness
Sandy or Gritty Feeling
Burning
Itching
Redness
Excess Tearing/Watering
Eye Pain or Soreness
Mucous Discharge
Have you been diagnosed with any of the following? Check the box if yes.
Cataracts
Crossed Eyes
Eye Injury
Glaucoma
Lazy Eye/Amblyopia
Macular Degeneration
Retinal Detachment
Dry Eye
Other:
Medical History
Medical Doctor
Practice Address
Last Medical Exam
MM slash DD slash YYYY
Review of Systems
Constitution
Development Disabilities
Cancer
Fatigue Syndrome
All Normal
Ear, Nose & Throat
Hearing Loss
Sinusitis / Sinus Pain
Dry Mouth
Laryngitis
All Normal
Neurological
Multiple Sclerosis
Epilepsy
Cerebral Palsy
Tumor
Migraine
All Normal
Psychiatric
Depression
Attention Deficit
Anxiety Disorder
Bipolar Disorder
All Normal
Cardiovascular/Cardiac
High Blood Pressure
Strove / CVA
Heart Disease
Vascular Disease
Congestive Heart Failure
All Normal
Respiratory
Asthma
Bronchitis
Emphysema
Chronic Obstruction
Sleep Apnea
All Normal
Gastrointestinal (GI)
Chron's Disease
Colitis
Ulcers
Acid Reflux
Celiac Disease
All Normal
Genitourinary
Kidney Disease
Prostate Disease/Cancer
STD - Herpetic/ Chlamydia
Benign Prostate Hypertrophy
Pregnant or Nursing
All Normal
Musculoskeletal
Arthritis
Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Osteoporosis
Gout
All Normal
Integumentary (Skin)
Eczema
Rosacea
Psoriasis
Herpes SImplex/Cold Sores
Herpes Zoster/Shingles
All Normal
Endocrine
Type 2 Diabetes Mellitus
Type 1 Diabetes Mellitus
Thyroid Dysfunction
All Normal
Hematologic/Lymphatic
Anemia
Hypercholesteremia
All Normal
Allergic/Immune
Environmental Allergies
Rheumatoid Arthritis
Lupus
Sjogren's Syndrome
All Normal
If you checked any of the above boxes or have a condition not listed, please explain further:
Are you allergic to any medications?
Yes
No
If yes, which ones?
Do you have a latex allergy?
Yes
No
Do you use alcohol:
Yes
No
Do you use tobacco products?
Yes
No
List any medications you are currently taking (include oral contraceptives, aspirin, over the counter medications)
Family History
Please note any family history (parents, siblings, children; living or deceased) for the following conditions:
Cancer
If checked above please note relation to you:
Type 1 Diabetes
If checked above please note relation to you:
Type 2 Diabetes
If checked above please note relation to you:
High Blood Pressure
If checked above please note relation to you:
Hyperthyroid Disease
If checked above please note relation to you:
Hypothyroid Disease
If checked above please note relation to you:
Cataract
If checked above please note relation to you:
Macular Degeneration
If checked above please note relation to you:
Glaucoma
If checked above please note relation to you:
Other: Please Specify
Signature
Date
MM slash DD slash YYYY
Optomap Retinal Screening Photography
While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough screening of the retina is critical to verify that your eye is healthy. This can lead to early detection of common diseases, such as glaucoma, diabetes, macular degeneration, and even cancer. The photos are quick, painless, and may not require dilation drops. More than 80% of your retina can be evaluated in one single image while traditional imaging methods typically only show 15% of your retina at one time. These photos will become a part of your medical records and will allow the doctor to compare them with subsequent photos at future exams in order to detect even the smallest amounts of change. Dilation is the only way 100% of your retina can be seen and can also help reduce the affects of your/your child's focusing which allows for a more accurate prescription.
There is an additional $39.00 screening fee for the Optomap retinal photo. This is not covered by insurance, but may be reimbursable by health savings/reimbursement accounts. Dr. Bhend highly recommends for complete retinal evaluation. Dilation has no additional charge at this time.
I choose to have the retinal screening photos taken and have my/my child's eyes dilated
I choose to have the retinal screening photos taken and decline having my/my child's eyes dilated.
I decline the retinal screening photo but I wish to have my/my child's eyes dilated at this time.
I decline both the retinal screening and dilation at this time. I understand this means the doctor will not get a complete view of the health of the eye.
Name of Patient
Signature
Today's Date
MM slash DD slash YYYY
Assignment of Insurance Benefits, Recall Program & Office Business Policies
I, the undersigned may have insurance coverage and/or vision plan coverage with an insurance carrier(s)/ or surgical benefits, if any, otherwise payable to me for services rendered. I hereby request that Bhend Family Eye Care, PLLC dba You and Eye to file any claim(s) for medical and or/ preventative care benefits with my medical carrier prior to filing a claim(s) with any vision plan carrier or free standing vision plan unless I indicate otherwise at time of service. I hereby authorize the release of all information necessary to secure the payment of benefits. As part of Dr. Bhend's annual recall program, I authorize Bhend Family Eye Care, PLLC dba You and Eye to utilize my name, mailing address, phone number, e-mail address and next appointment date and time to Bhend Family Eye Care, PLLC dba You and Eye for the purpose of providing annual reminder postcards, coupons and product information. I understand that I am financially responsible for all charges whether or not paid by insurance or vision plans; Co-pay, Co-insurance, and Deductibles are due at the time of service; Contact lens fitting fees, which are not generally covered by insurance nor a part of a routine eye exam, are due at the time of service; Bhend Family Eye Care, PLLC dba You and Eye charges $30.00 for any check returned from your bank; returned check fee(s) will be added to my unpaid balance and must be paid by credit card or in cash. Contact lens fitting fees are good for 90 days from date of original contact lens fitting; any contact lens fitting not completed within 90 days may incur additional fees.
Signature
Date
MM slash DD slash YYYY
Privacy Policy (HIPAA)
I acknowledge that I have either been given access to and reviews or received a copy of the Office's Notice of Privacy Practices, ("Notice") which describes how my health information is used and shared. I understand that the Office has the right to change this Notice at any time. I may obtain a current copy by contacting the Office Privacy Officer.
CLICK HERE TO VIEW OUR NOTICE OF PRIVACY PRACTICES
Signature
Date
MM slash DD slash YYYY
If you do not wish to receive text messages or email notifications please VERBALLY notify a staff member so we may modify your file.
Notice of Privacy Practices
In signing this authorization to release my protected health information, I acknowledge that I understand my right to medical information confidentiality and authorize You and Eye Family Eye Care Center to discuss all my medical health information with the individual)s) listed below:
Name
Relationship
I do not wish to share any of my information with any other individuals.
Signature
If you don't receive confirmation for this registration within 24 hours of completing, then it's likely your registration didn't go through. Please call the office to complete over the phone.
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