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You and Eye Patient Registration
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2019-02-07T21:39:23+00:00
You and Eye - Dr. Kristy Bhend
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Patient Registration
Today's Date
*
MM slash DD slash YYYY
Title
Mr.
Ms.
Miss
Mrs.
Dr.
Other
Please specify
Name
*
First
Last
Nickname
Date of Birth
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MM slash DD slash YYYY
Age
Sex
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Marital Status
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Address
Street Address
Address Line 2
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Afghanistan
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Country
Home Phone (or Cell if no home)
*
Cell Phone
Work Phone
Social Security Number
XXX-XX-XXXX
Email
*
Do You Wear Contacts?
*
Yes
No
Would You Like Text Reminders?
Yes
No
Emergency Contact
Mr.
Mrs.
Miss
Ms.
Dr.
Prefix
First
Last
Emergency Contact's Relationship to Patient
Home Phone
Cell Phone
How Did You Hear about Us?
Insurance
Web Search
Facebook
Yelp
Yahoo
Google
Friend
Other
Name
First
Last
Other: Please Specify
Employment Information
Occupation
Status
Full-time
Part-time
Retired
Not Employed
Employer
Employer Phone
Vision Insurance Information
(1st) Primary Insurance
ID Number
Subscriber's Name
First
Last
Plan Number
Subscriber's Birth Date
MM slash DD slash YYYY
Patient's Relationship to Subsriber
Self
Spouse
Child
Other
Other: Please Specify
Medical Insurance Information
(1st) Primary 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 Subsriber
Self
Spouse
Child
Other
Other: Please Specify
Medical Information
Patient/Guardian Name
First
Last
Date of Birth
MM slash DD slash YYYY
Medical History
Select all that Apply
Constitutional
Development Disability
Cancer
Fatigue Syndrome
Weight Loss / Gain
Trauma / Recent Injury
None
Ear, Nose & Throat
Hearing Loss
Ringing in Ears
Sinusitis / Sinus Pain
Dry Mouth
Laryngitis
None
Neurological
Multiple Sclerosis
Epilepsy
Tumor
Migraine
Strove / CVA
None
Psychiatric
Depression
ADHD / Attention Deficit
Anxiety
Bipolar Disorder
Other
None
Cardiovascular
High Blood Pressure
Strove / CVA
Heart Disease
Vascular Disease
Congestive Heart Failure
None
Respiratory
Asthma
Bronchitis
Emphysema
Chronic Cough
COPD
None
Gastrointestinal (GI)
Chron's Disease
Colitis
Ulcer
Acid Reflux / GERD
Celiac Disease
None
Genitourinary (GU)
Pregnant or Nursing
Kidney Disease
Prostate Disease / Cancer
Urinary Tract Infections
STD - HIV, Herpes, Chlamydia
None
Musculoskeletal
Arthritis
Osteoarhritis
Fibromyalgia
Ankylosing Spondylitis
Muscular Dystrophy
Osteoporosis
None
Integumentary
Eczema
Rosacea
Psoriasis
Herpes SImples / Cold Sores
Herpes Zoster / Shingles
None
Endocrine
Insulin Resistance / Pre-diabetes
Type 2 Diabetes Mellitus
Type 1 Diabetes Mellitus
Thyroid Dysfunction
Hormonal Dysfunction
None
Hematologic
High Cholesterol
Aspirin Use
Anemia
Large-Volume Blood Loss
Bleeding Disorder
None
Immune
Rheumatoid Arthritis
Lupus
Sjogren's Syndrome
Painful or enlarged glands
Compromised Immune System
None
Social
Alcohol Use
Tobacco Use
None
What are your hobbies?
Allergies
Allergies to Medication
Enviromental
None
Allergies to Medications: Please List
All Current Medications
Please List with Dosage
Patient Eye History. Select all that apply
Blindness
Cataracts
Corneal Problems
Diabetic Retinopathy
Dry Eye
Eye Allergy
Eye Injury
Floaters/Spots
Light Flashes
Frequent Eye Infections/Styes
Glaucoma
Glaucoma Suspect
Iritis/Uveitis
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment/Tear
Other
None
Other: Please Specify
Has Patient's Family Experienced Any of These Medical Conditions? Select all that apply.
Blindness
Cataracts
Corneal Problems
Diabetic Retinopathy
Dry Eye
Eye Allergy
Eye Injury
Floaters/Spots
Light Flashes
Frequent Eye Infections/Styes
Glaucoma
Glaucoma Suspect
Iritis/Uveitis
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment/Tear
Diabetes
Thyroid Disease
Other
None
Other: Please Specify
Are you or anyone in your family red/green color deficient?
Yes
No
If so, whom?
Any Patient Surgeries? Select all that apply.
Cataract
Corneal Transplant
Eye Muscle Surgery
Glaucoma Laser
Glaucoma Surgery
LASIK/PRK
Retinal Laser
Retinal Surgery
Retinal Injections
RK Incisions
Yag (Laser After Cataract)
Other
None
Other: Please Specify
Has Patient's Family Undergone Any of The Procedures below? Select all that apply.
Cataract
Corneal Transplant
Eye Muscle Surgery
Glaucoma Laser
Glaucoma Surgery
LASIK/PRK
Retinal Laser
Retinal Surgery
Retinal Injections
RK Incisions
Yag (Laser After Cataract)
Other
None
Other: Please Specify
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
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.
Signature
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