SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
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1 SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE OR & TEXT MAILING ADDRESS: CITY: STATE: ZIP: CIRCLE ONE: CHILD - SINGLE - PARTNER - MARRIED SPOUSE OR PARTNER S NAME: IF PATIENT IS A MINOR, FILL OUT PARENT INFO BELOW MOTHER S NAME: DOB: ADDRESS: CITY: STATE: ZIP: CONTACT #: CIRCLE: HOME, CELL, WORK FATHER S NAME: DOB: ADDRESS: CITY: STATE: ZIP: CONTACT #: CIRCLE: HOME, CELL, WORK INSURANCE INFORMATION PRIMARY INSURANCE: INS ID #: NAME OF INSURANCE HOLDER (employee): DOB: RELATIONSHIP TO PATIENT: EMPLOYER: 2NDARY INSURANCE: INS ID #: NAME OF INSURANCE HOLDER (employee): DOB: RELATIONSHIP TO PATIENT: EMPLOYER: EMERGENCY CONTACT (SOMEONE OTHER THAN THOSE LIVING WITH PATIENT) NAME: CONTACT #: RELATIONSHIP TO PATIENT:
2 SILVERDALE EYE PHYSICIANS NOTICE OF PRIVACY PRACTICES - ACKNOWLEDGEMENT We keep a record of health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our Privacy Officer. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information. By my signature below I acknowledge receipt of the Notice of Privacy Practices, or know that I may obtain a copy if I so wish. Signature of patient or legally authorized individual Date Print name Relationship (self, parent, legal guardian, etc) Who else may have access to my healthcare information and make appointments for the patient? Name Relationship Phone Name Relationship Phone
3 Silverdale Eye Physicians Financial Policy Thank you for choosing SILVERDALE EYE PHYSICIANS as your health care providers. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. FULL PAYMENT OF COPAYS, AND NON-INSURED PROCEDURES ARE DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, AND DISCOVER. Regarding Insurance We accept assignment of most insurance companies. However, we may require any co-pays, deductibles, or non-covered procedures to be paid at the time of service, or before any surgeries. As a courtesy to you, we will bill most insurances for you. However, the balance is your responsibility if the insurance company does not pay or you have a deductible, or co-insurance to meet. If your insurance company has not paid your account in full within 45 days of service, the balance will be automatically transferred to you. Please be aware that some of the services provided may be non-covered and not considered reasonable and necessary under your insurance. Vision plans we accept: Northwest Benefit Network (NBN). We are NOT providers with Vision Service Plan (VSP), Davis/Blue Vision, Eye Med or Spectera. Usual and Customary Rates Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area for specialists. You are responsible for payment regardless of your insurance company s determination of not medically or not covered procedures, or lack of authorizations your insurance may require to be seen. Please verify any necessary authorizations needed are in place. Cancel Late, No Show & Returned Checks If you are unable to keep your scheduled appointment, please call the office 24 hours before your appointment to reschedule in order to accommodate another patient. If you cancel or no show without 24 hours notice, we reserve the right to assess a $50 fee. A total of three no shows or cancellations may result in discharge from our office. If you are more than 15 minutes late, you may be charged a cancellation fee, and your appointment may be rescheduled. If there is a check returned from your bank, (Non Sufficient Funds), you will be charged $50 for each occurrence. I understand and agree to this Financial Policy. I give permission to bill my insurance company. I further authorize you to release any information needed to determine what benefits might be payable for service rendered. X Date Signature of Patient or Responsible Party Print Name
4 HEALTH HISTORY Patient Name: DOB: Primary Doctor: Referring Doctor: Occupation: Hobbies: Smoking History: Alcohol Drinks Per Day: Ethnic Background: When was your last eye exam? What can we help you with today? (circle all that applies) Blurred vision Eyestrain Double vision Spots in vision Headaches Existing eye disease Trouble seeing at night Red eyes One eye turns in or out Pain with bright lights Interested in contacts Existing Systemic Disease Dry eyes Itching eyes Flashes of light Crusts in eyes Update glasses Floaters Watering eyes Pain in or around eyes Halos around lights Wavy distorted vision Update contact lens Eye History (circle all that applies) Macular Degeneration Glaucoma Cataracts Retinal Detachment Amblyopia Strabismus Corneal Transplant Do you currently wear glasses? Do you currently wear contacts? Yes No Yes No List below other eye conditions not mentioned Ocular Surgery or Trauma: Other Medical History (circle all that applies) Diabetes High blood pressure Heart disease Cancer High cholesterol HIV or AIDS Stroke Thyroid disease Asthma Arthritis Hepatitis Blood clotting disorder General surgeries: Your Current Medications (if you have a list today skip this section and show list to Technician) Pills: Eye Drops: Allergies to Medications:
5 Please circle all that applies GENERAL: NONE / FEVER / WEIGHT LOSS / NO APPETTE / FATIGUE / EXCESSIVE THIRST SKIN, JOINTS: NONE / RASHES / ECZEMA / ARTHRITIS / ROSACEA EARS, NOSE, THROAT: NONE / HEARING LOSS / SINUS PROBLEMS LUNGS: NONE / ASTHMA / EMPHYSEMA / BRONCHITIS HEART: NONE / HIGHT BLOOD PRESSURE / LOW BLOOD PRESSURE / IRREGULAR HEART BEAT / HEART FAILURE / OTHER ABDOMINAL: NONE / DIARRHEA / CONSTIPATION / ULCER / GI BLEEDING GENITOURINARY: NONE / FREQUENT URINATION / IMPOTENCE / INFECTION / KIDNEY STONES NEUROLOGIC: NONE / MIGRAINES / HEADACHES / STROKE / ALZHEIMER S / PARKINSON S ENDOCRINE: NONE / LOW THYROID / HIGH THYROID / INSULIN DIABETES / NON INSULIN DIABETES BLOOD: NONE / ANEMIA / EASY BRUISING / HIV VIRUS / PRIOR TRANFUSION PSYCHIARTIC: NONE / DEPRESSION / BIPOLAR / ANXIETY / POOR MEMORY / ADD/ADHD HAVE YOU EVER TAKEN STEROID MEDICATION OF ANY KIND? YES NO ARE YOU CURRENTLY TAKING ANY ASPIRIN RELATED DRUGS? YES NO
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
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Arthur M. Cotliar, M.D. & Staff
Dear Patient: Thank you for taking time to schedule an appointment at one of our offices. Please fill out the enclosed forms and bring the forms with you on the day of your appointment. In addition, please
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Patient s Full Legal Name: DOB: Sex: M F. SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip:
Patient Information: Date: Patient s Full Legal Name: DOB: Sex: M F SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip: Home Phone: Cell Phone: Daytime Phone: Email: Approved Communication:
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Please Your Preferred Contact Number
PATIENT INFORMATION First Name: MI: Last Name: Nick Name: Address: City: State: Zip: PHONE NUMBERS Date of Birth: / / Please Your Preferred Contact Number Cell: Sex: M F Work: Status: Single Married Widowed
PATIENT REGISTRATION FORM
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Rev. Your Address Street or P.O. Box City State Zip. Your Date of Birth / / SS# Phone numbers cell ( ) - home ( ) - work ( ) -
Welcome to Our Office This information will allow us to begin the process that ensures your eye health and vision remain at their best, and that your health and lifestyle needs are met. Thank you for your
Name Today's Date Sex / / Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
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Complete Your Personal Information Salutation Mr. Mrs. Ms. Dr. Miss. Master Rev. First Name* Last Name* Preferred Name
Please take a few minutes to complete this Patient Welcome Form before you visit our office for the first time. Print it out, fill it in, and bring the copy with you to your next appointment. Complete
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
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Patient Information Last Name First Name Middle Initial
Patient Information Last Name First Name Middle Initial Street Address Apt# City State Zip Code Social Security # Home Phone Cell Phone Email D.O.B Sex(M/F) Occupation Relation to Insured Self Spouse Child
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We Kids and Teens! Welcome to Our Office This information will allow us to serve the child and parents or guardians best. Thank you for your help. Patient s Name Last First Middle Nickname or Preferred
PATIENT REGISTRATION. Patient s Name: (Last) (First) Home Address: City State Zip. Home Phone: Cell Phone: Work Phone:
PATIENT REGISTRATION Date: Patient s Name: (Last) (First) Home Address: City State Zip Home Phone: Cell Phone: Work Phone: Email Address: May we call you at work? Yes No Date of Birth: Sex: M / F / Other
Dear Patient: APPOINTMENT DATE IS: TIME: We look forward to seeing you and providing your eyecare for years to come. Thank you,
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PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT
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Patient Information. Morris Neel, O.D. P.A Whitley Rd, Watauga, TX Tiffaney Tregellas, O.D. Emily Horn, O.D.
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Patient s Full Legal Name: DOB: Sex: M F. SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip:
Patient Information: Date: Patient s Full Legal Name: DOB: Sex: M F SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip: Home Phone: Cell Phone: Daytime Phone: Email: Approved Communication:
CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY
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Skin Problems Unexpected weight Loss/Gain None Explain: None Endocrine: Self Family: Musculoskeletal: Self Family: Thyroid
Demographics Last Name: First Name: Initial: : Guarantor: Address: City: State: Zip: Home #: Work #: Cell #: Email: Communication Preferred: email phone mail Pharmacy of Choice: of Birth: Male Female Ethnicity:
If you circled married, please complete Spouse s Information below: Spouse s Last Name: First Name:
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PATIENT INFORMATION. Patient s Last Name First M.I. Home Phone Work Phone Cell Phone Home Address City State Zip Address
PATIENT INFORMATION Patient s Last Name First M.I. Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Address Social Security # Sex Marital Status Patient s Date of Birth Age Spouse s
Dear Patient: APPOINTMENT DATE IS: TIME: We look forward to seeing you and providing your eyecare for years to come. Thank you,
Lawrence D. Castleman, M.D. John M. Ramocki, M.D. Snigdha Singh, M.D. James R. Valice, M.D. Dear Patient: Please fill out the enclosed paperwork and bring it to your exam along with your insurance cards.
MEDICAL FORM (Please Fill in all Information)
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RESPONSIBLE PARTY DEMOGRAPHIC INFORMATION
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S T E P 1 PAT I E N T I N F O R M AT I O N
Please complete the FRONT AND BACK of each page Date Last Name First Name MI Address City State Zip Phone: Home ( ) Work ( ) Cell ( ) SS# Date of Birth Age E-Mail Address Marital Status Ethnicity ] Married
1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.
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PEDIATRIC REGISTRATION FORM
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ADULT VISION QUESTIONAIRE
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PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
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COSMETIC HISTORY FORM
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RICHARD J. MANGANIELLO, MD Connecticut Eye Physicians and Surgeons, LLC 479 Buckland Road, South Windsor, CT 06074
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Preferred Name. Address Zip: Name of Family Physician. Emergency Contact EYE HISTORY. Date of last exam
Name Date of Birth Age Cell Phone Email address Preferred Name Height Weight Male/Female/Other May we leave a message? Yes/No May we email you? Yes/No Address Zip: Employer (or School) Name of Family Physician
PATIENT INFORMATION NOTICE OF PRIVACY POLICY PATIENT ACKNOWLEDGEMENT
PATIENT INFORMATION ( MR / MRS / MS / DR ) FIRST MIDDLE LAST DATE OF BIRTH AGE MARITAL STATUS (circle one) Married / Divorced / Single / Widowed STREET ADDRESS APT/LOT/ROOM/SUITE CITY STATE ZIP GENDER
West Houston Infectious Disease Associates. Address: Number Street Apt. No. City State Zip. Home Phone: Cell: Work:
Carson T. Lo M.D. West Houston Infectious Disease Associates Linda S. Yancey, M.D. NEW PATIENT INFORMATION Thank you for choosing West Houston Infectious Disease Associates. Please completely fill out
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Patient Information Date: Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Male Female Social Security #: Birth Date: / / Age: Local Phone: ( ) Cellular Phone: ( ) Email Address:
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EYES OF THE SOUTHWEST New Patient Information
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Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?
Social Security No: Home Phone: _. Employer: Work Phone: _. Employer Address: Occupation: _. Spouse/Parent Name: Phone No: _
THE NATIONAL RETINA INSTITUTE LEADERS IN THE TREATMENT OF RETINAL DISEASES Patient Information Form Patient Name: Date of Birth: -,--I _----'--/ Age: Social Security No: Home Phone: _ Street Address: --------------------------------------
PLEASE PRINT AND COMPLETE ALL ENTRIES
Patient Name: (Last, First, MI) E-mail Address: PLEASE PRINT AND COMPLETE ALL ENTRIES Date of Birth: / / Male Marital Status: S M Minor Female D W Your Social Security No: Address: Street Home Phone: Address:
Date of Birth: Age: Social Security #: Address: City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div
Your Name: Email Address: Date of Birth: Age: Social Security #: Address: _ City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div Spouse s Name: Emergency Contact: Telephone
Name (Last, First, MI): Date of Birth: / /
Name (Last, First, MI): Address: Age: City: State: Zip: Sex: Male / Female Phone #: (Home): (Cell): (Work): Personal Email: Social Security #: Race: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Other
Patient Name M/F D.O.B. / /
Patient Name M/F D.O.B. / / Phone ( ) Cell ( ) STATUS: Single Married Divorced Widow Soc. Sec. # - - Insurance Name Group Policy # Guarantor Subscriber Occupation /Student Work Place Email @. (Please provide
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Patient Registration Form This form is posted on our website
Patient Registration Form This form is posted on our website www.kidseyecare.net Caring For the Vision of Our Future Patient Last Name: First Name: Sex : Male / Female Date of Birth: SS #: - - Phone: (
Attleboro Vision Care Associates, P.C. 550 North Main Street Attleboro, MA (508)
Attleboro Vision Care Associates, P.C. 550 North Main Street Attleboro, MA 02703 (508) 222-9912 Dear New Patient: Welcome to Attleboro Vision Care Associates, P.C. Please complete the enclosed Patient
X PRINT PATIENT S NAME DATE OF BIRTH SIGNATURE
Surgery Partners Affiliated Covered Entity (SPACE) 2017 ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I have received the attached Privacy Notice. X PRINT PATIENT S NAME DATE OF BIRTH
Please Present Insurance Card at Each Office Visit
PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
NEW PATIENT INFORMATION Salutation First Name MI Last Name Nickname
NEW PATIENT INFORMATION Salutation First Name MI Last Name Nickname of Birth: Address: SSN: City: State: Zip: Home Phone: Daytime Phone: Mobile Phone: Which number do you prefer we use to contact you?
LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# ADDRESS:
PATIENT INFORMATION LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# EMAIL ADDRESS: OCCUPATION: EMPLOYER: RACE: ETHNICITY: White
Welcome to our Practice
Welcome to our Practice First, let us thank you for putting your trust in Georgia Eye Partners and our team. Our goal in providing this packet of information is to make the process as easy as possible
PATIENT S INFORMATION
David O. Magnante, M.D. 975 Mezzanine Drive, Suite B Lafayette, IN 47905 PH: 765449.7564 FX: 765.807.7943 PATIENT S INFORMATION Patient s Social Security# - - Date Name Last First Middle Initial Home Address
Website: Optometry: Ophthalmology: _ George E. White O.D. FAAO George R. Pronesti M.D.
Print Name: DOB: Emergency Contact: Relationship: Phone #: Person(s) we may share private health information with: Relationship: Primary Care Physician: Pharmacy: ******** ALL PAYMENTS ARE DUE AT TIME
Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS
WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions we ll be glad to help you. We look forward to
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM PATIENT DATA Last Name: First Name: Middle Initial: Date of Birth: Social Security [last 4 digits]: Female Male Occupation: Employer: PREFERRED METHOD OF CONTACT Home phone: Preferred
Patient Registration
Today s : Patient Registration Name: (First, MI, Last) of Birth: Age: Gender: M F Marital Status: S M D W Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: Email Address: Preferred Daytime
WELCOME TO OUR PRACTICE! We look forward to seeing you very soon.
WELCOME TO OUR PRACTICE! We are glad to welcome you to Park Avenue Oculoplastic Surgeons (PAOS) and Park Avenue Surgery Center (PASC). Enclosed are some materials which will acquaint you with our facilities,
ERIC ROCKMORE, DPM, FACFAS
Date: Name Date of Birth Address City State Zip Code Email Address Preferred Language Social Security(Medicaid only) Referred by Gender Race Ethnicity Home# ( ) Work # ( ) Cell ( ) Preferred phone # (
I Federal Law requires us to ask race: Hispanic Non-Hispanic
Today's Date < McCoy VISION Please Contact Me at this Number Patient Registration Chart# - Patient's Name (last, first, middle initial) Date of Birth Sex Home Phone Street Address City State Zip Work
Thank you very much for choosing us and we look forward to your visit!
Main: 136 W. Cherry St Jesup, GA 31545 Brunswick: 17 Professional Dr Suite 100 Brunswick, GA 31520 Ophthalmology Phone: (912) 559-2467 Fax: (912) 559-2473 www.crandalleye.com Dear, Thank you for choosing
Brian D. Haas, M.D., PL PATIENT INFORMATION
Brian D. Haas, M.D., PL PATIENT INFORMATION NAME: Last First M DATE: / / ADDRESS: Street City State Zip Code Married Single Widowed Divorced Social Security # Sex: M F Birthday: / / RACE: ETHNICITY: PRIMARY
MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information
Patient Information Patient Name Last First Middle Address City State Zip Birthdate Age Sex M F Social Security# Race (Please circle) American Indian Asian Black Native Hawaiian Pacific Islander White
Welcome to Williamson Eyecare your Vision Source
Please complete the following forms in its entirety. Last Name First Name MI Address City State Zip Date of Birth Age Social Security # Marital Status Home Phone Cell Phone E-Mail Please list BOTH vision
INSTRUCTIONS. Once you complete the forms, save the file to your desktop for your records, then attach in an to:
INSTRUCTIONS For your convenience you can fill out the following forms on your computer if you have Adobe Acrobat Reader installed. Fields are highlighted in blue. Use the tab key to move from field to
TENNESSEE LASIK LASIK PATIENT INFO PACKET. clipboar. Privacy Practices. Patient Information. Medical History Questionaire
LASIK PATIENT INFO PACKET Privacy Practices Patient Information Medical History Questionaire Notice of Privacy Practices 1. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED