Preferred Name. Address Zip: Name of Family Physician. Emergency Contact EYE HISTORY. Date of last exam
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1 Name Date of Birth Age Cell Phone address Preferred Name Height Weight Male/Female/Other May we leave a message? Yes/No May we you? Yes/No Address Zip: Employer (or School) Name of Family Physician Date of last physical check up Occupation (or Grade) City Preferred Pharmacy Emergency Contact EYE HISTORY Date of last exam By whom Have you ever experienced, been diagnosed with or treated for any of the following? Blurry Vision Flashes of Light Swelling Burning Floaters/Spots Loss of Vision Cataracts Glare Macular Degeneration Crossed Eye/Eye Turn Glaucoma Retinal Detachment Double Vision Halos Sunlight Sensitivity Dryness Iritis/Uveitis Trouble Seeing at Night Eye Infections Itchiness Vision Fluctuation Eye Injury Lazy Eye Watering Eyes Other How many hours per day do you spend on a computer/tablet/phone? Are you currently interested in glasses, contact lenses or both? Glasses Contacts Both Do you currently wear glasses? Yes No Age at First Pair of Glasses Are you satis ied with your vision? Do you currently wear contact lenses? Yes No Yes ill out below No continue to next page Brand/type Average hours wearing time/day Solutions used Are you interested in upgrading to the latest contact lens technology? Yes No
2 MEDICAL HISTORY Have you ever been diagnosed or treated for the following health problems? * By checking this box, you con irm you have never been diagnosed with any medical condition Allergies Dry Mouth Kidney Issues Anemia Emphysema Migraines Arthritis Headaches Nursing (currently) Bronchitis Heart Disease Psychological Cancer High Blood Pressure Pregnant (current/trying) Chronic Cough High Cholesterol Rosacea Epilepsy HIV +/AIDS Seizures Diabetes Irritable Bowel/Crohn s Sinus Issues Dizziness Joint/Muscle Pain Thyroid Other Current Medications (RX or over the counter) *We can photocopy your list of medications if you have them Allergies to medications? No Yes what medications? Have you had any eye surgeries? No Yes what? Alcohol: Never Former Current Recreational substances: Never Former Current Tobacco Products: Never Former Current FAMILY MEDICAL HISTORY Is there a family history of the following? Relationship: Relationship: Diabetes Blindness Heart Disease Glaucoma Cancer Lazy Eye/Eye Turn Macular Degeneration Do you agree to be dilated today to have the health of your eyes thoroughly examined by Dr. Dunn? Yes Unsure, I would like to talk to the doctor about it The information I have provided, to the best of my knowledge, is accurate Patient or guardian signature Doctor Reviewed
3 Preventative and Wellness Consent In our continued efforts to provide the highest level of eye care, and to bring the most advanced technology available to our patients, Gatti Vision is proud to offer our patients an advanced Preventative and Wellness Screening using our state of the art technology. Analyzing these extremely high-resolution images is an excellent technique for diagnosing and monitoring diseases like GLAUCOMA, MACULAR DEGENERATION or DIABETIC RETINOPATHY. Imaging performed today establishes a baseline for future exams. This makes it possible for Dr. Dunn to detect any changes in your eyes over time with extreme precision. It is now the standard of care to perform retinal imaging during comprehensive eye examinations at Gatti Vision. I accept this standard of care for $25.00 *This is not covered by insurance and can be paid by cash, check or credit card* I decline the advanced imaging against my doctor s recommendation. Signature Date
4 15405 SW 116TH AVE UNIT 204 KING CITY OR, (971) Written Financial Policy Thank you for choosing Gatti Vision LLC. Our primary mission is to deliver the best and most comprehensive care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options: You can choose from: Cash, Check, or accepted credit cards CareCredit healthcare credit card. CareCredit is the preferred healthcare credit card providing 1 special financing and payment options * for out of pocket medical expenses. Ask about how the CareCredit healthcare credit card can help you. We offer a 12% courtesy adjustment to uninsured patients who pay day of service for their vision care. Please note: It is customary to pay for professional services when rendered. However, if you have a medical problem then we will bill your medical insurance on your behalf. During your comprehensive exam, a refraction will be performed. A refraction is a measurement of the lens power necessary to prescribe glasses or other corrective lenses. Most medical insurance plans, including Medicare, do not cover routine refractions or routine eye exams (when no medical eye problem is known or suspected). Medicare, and most other insurance plans, insists that we charge separately for that portion of the examination, since it is not a covered service. You will receive an explanation of benefits from them itemizing your responsibilities. You will be responsible for any co payments, deductibles or non covered services as determined by your insurance company. Contact lens exams are not part of comprehensive exams. There may be an additional fee for these exams and fittings if they are not covered by your insurance. If you have a separate plan that covers routine or annual eye examinations and/or hardware, please let us know. Your vision plan may assist you with your eye care needs that are not covered by your medical plan. We will bill your vision plan as above. We are a Medicare participating practice. If you are a Medicare Beneficiary, we will file a claim for you. You will be responsible for the annual deductible and the 20% co payment. MINORS ACCOMPANIED BY AN ADULT; The adult accompanying a minor and his/her parents (or guardian) are responsible for payment upon completion of your exam or consultation. 1* Subject to credit approval
5 In accordance with our contract and with your insurance provider, we are responsible for collecting, and you are responsible for paying, co payments after your exam. Gatti Vision LLC requires payment after the exam or consult. Gatti Vision LLC requires a payment be made in full prior to the order of your optical purchases. Gatti Vision LLC requires a fee for the refraction of $35 (if your insurance does not cover it). *See above Gatti Vision LLC will verify your insurance eligibility prior to your appointment. If you have any questions, please do not hesitate to ask. We are here to help you get the quality care you want or need. * However, if we do not receive payment from your insurance carrier within days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier. Vision vs. Medical Insurance 1.) Vision Insurance Examples: VSP, EyeMed, Spectera, etc. Routine vision exams with copay Hardware and contact lenses with copay Does not cover medical eye care (dry eyes, allergies, injuries, etc.) 2.) Medical Insurance Examples: BCBS, Medicare, Cigna, Providence, etc. Used for medical eye care (diabetes, dry eyes, allergies, injuries, infections, etc.) If a medical eye condition is discovered during your comprehensive vision exam, Dr. Dunn may ask you to return for a progress evaluation. If you have both types of insurance, we will bill the insurances appropriately. We will try to minimize your out of pocket expense. If some fees are not covered by insurance you will be responsible for them. For example, deductibles, co pays, and non covered services as allowed by our insurance contract. Please provide all insurance information you may have by time of service so that our staff can record all of your coverages. We need to have a copy of all insurance cards on file in case we need to bill your insurance for future exams. If insurance is not provided, fees will be the responsibility of the patient. By signing below, you acknowledge that you have read and understand this document. Patient, Parent or Guardian Signature Date Patient Name (Please Print)
6 RETURN/EXCHANGE POLICY Gatti Vision LLC does not allow returns or exchanges on frames, reading glasses, or sunglasses. This includes all accessories and cleaners. All sales are final. We take the time to help you pick out the best products and ensure you are satisfied before leaving the office. Gatti Vision LLC does not allow returns or exchanges on artifical tears, warm compresses, Alaway, Omega 3s, lid scrubs, or contact lens solution. All sales are final. We are a medical practice and therefore cannot allow any returns or exchanges whether opened or unopened. By signing below, you understand that once purchased, the product is unreturnable. Patient, Parent or Guardian Signature Date Patient Name (Please Print)
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
Crystal L. Franklin, OD, PA 8247 Ocean Highway, Pawleys Island, SC Phone: Fax: REGISTRATION FORM PATIENT INFORMATION
REGISTRATION FORM Today s date: Patient s last name: First: Middle: Is this your legal name? Email Address: PATIENT INFORMATION Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep /
SCHWARTZ EYE ASSOCIATES
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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
NOTICE ABOUT REFRACTION
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PATIENT REGISTRATION
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Welcome to West County Vision Center
Welcome to West County Vision Center Thank you for choosing our office for you eye care needs! Please take a moment to complete the following information. If you have any questions, please do not hesitate
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
Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA Phone: Fax:
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Lawrence Eye Care Associates, P.A.
Dear Patient: Enclosed you will find paperwork that you will need to complete and bring with you on the day of your scheduled appointment. You will only need to complete this paperwork if you are a new
NOTICE ABOUT REFRACTION
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SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S EMAIL: DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE
Name Last First Middle Address. City State Zip. Home Phone ( ) Date of Birth Age Marital Status. Work Phone ( ) Address. Employer Occupation
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Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
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PATIENT REGISTRATION AND HISTORY FORM ~ FAMILY EYE HEALTH ASSOCIATES
PATIENT REGISTRATION AND HISTORY FORM ~ FAMILY EYE HEALTH ASSOCIATES PATIENT INFORMATION: Name (Last, First, MI) Date: Address: City State Zip Home Phone 2nd Phone Work Cell E-Mail Gender: M F Birthdate
If you circled married, please complete Spouse s Information below: Spouse s Last Name: First Name:
METROPOLITAN EYE CARE Scott B. Pomerantz, M.D. Thomas J. LoPresti, O.D Lori R. Kaplan, O.D. 523 Forest Avenue Paramus, NJ 07652 Tel. (201) 262-5070 Fax (201) 262-5333 Please Complete and Sign Where Indicated
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.
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
REGISTRATION INFORMATION [PLEASE PRINT]
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MARVIN C. MAH, O.D REGISTRATION INFORMATION [PLEASE PRINT] Patient Age Birthday Last Name First Name Sex M F Social Security # Today s Date Address City Zip Home Phone Business Phone Cell Phone Occupation
PATIENT INFORMATION PRIMARY INSURANCE INFORMATION
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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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INSURANCE INFORMATION
PATIENT INFORMATION Patient Name: Dr., Mr., Mrs., Miss, Ms. Home Address: City: State: Zip: Reason for Visit: Email: Phone: Date of Birth: Sex: Male Female Social Security No.: Who Referred You: WORK INFORMATION
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
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S EMAIL: DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE
Important Insurance Information Please review and sign below so we can process your claim accurately and efficiently
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Eye Associates of Georgetown, LLPC
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Please bring the following to your appointment:
Welcome to our office! We appreciate the confidence and trust that you have placed in us and look forward to meeting you personally and professionally. Our philosophy of care governs everything we do for
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:
Greenbriar Vision Center Welcomes You Please Print Clearly
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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
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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
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
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
Name: (Last) (First) (M.I.) (Nick Name) Address: City: State: Zip: Address:
Date: / / Welcome and thank you for choosing McCabe Vision Center for your eye care needs. We take pride in providing you with the best vision correction possible. : (Last) (First) (M.I.) (Nick ) Address:
Welcome Packet New Patient
Hello, We excited to welcome you to Southern Eye Associates. It is a pleasure having the opportunity to begin taking care of your eye health. ur practice and providers have had the opportunity to take
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.
ANN BULLINGTON, M.D. ROBERT H. BULLINGTON, JR., M.D. Cornea and External Diseases AILEEN F. VILLAREAL, M.D. ROBERT E. FINTELMANN, M.D., F.A.C.S. Cornea, Cataract, and Refractive Surgery Welcome to Biltmore
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
RICHMOND EYE ASSOCIATES, P.C.
D. ALAN CHANDLER, M.D. MALCOLM MAGOVERN, M.D. HAROLD A. BERNSTEIN, M.D. DAVID M. BOWMAN, M.D. DONALD W. LUMPKIN, JR., O.D. CINDY KOZA, O.D. Welcome to Richmond Eye Associates! Thank you for choosing Richmond
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
Dear patient: We welcome you to our practice and ask that you kindly complete or correct all information on this form.
Account No: WELCOME LETTER Dear patient: We welcome you to our practice and ask that you kindly complete or correct all information on this form. PATIENT INFORMATION PATIENT NAME: SEX: LAST FOUR SOCIAL
Eugene Eye Clinic, LLC
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PRE-EXAM QUESTIONNAIRE
Matthew T. Stanley, O.D. Darcy D. Stanley, O.D. Doctors of Optometry Patient #: PRE-EXAM QUESTIONNAIRE Name: Sex: M F Today s Date: / / Name you prefer to be called: Home Phone: Street Address: Daytime
Checklist for Your Eye Doctor Appointment at
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Lifestyle Questions
personalized eye care and eyewear boutique Patient Information WELCOME TO OUR OFFICE Today s Date Last First (Legal Name) MI Preferred Name Street City State Zip Code Preferred Phone Alternate Phone Patient
New Patient Questionnaire. Patient Full Name: Date: Street Address: City: State: Zip Code: Primary Care Physician: Pharmacy:
New Patient Questionnaire Patient Full Name: Date: Street Address: City: State: Zip Code: Home Phone: Cell Phone: Social Security #: - - Date of Birth: Age: Sex: q M q F Email: Marital Status: qs qm qd
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:
Vision Source! Greenspoint WELCOME TO OUR OFFICE
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Attleboro Vision Care Associates, P.C. 550 North Main Street Attleboro, MA (508)
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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:
Welcome To Our Office
Welcome To Our Office Date: Patient Name: SSN Date of Birth Address City State Zip Home Number:( ) Cell:( ) Work Number:( ) Email Address: Occupation (student) Employer (grade) Primary Care Physician Phone
PATIENT AGREEMENT. For medical records questions, please contact a medical records assistant at (952)
OFFICE USE ONLY PN: DOS: PATIENT AGREEMENT Consent for Treatment I authorize Minnesota Eye Consultants to assess and treat me, complete tests, and administer medications considered necessary or advisable.
Welcome! Please fill out completely
Welcome! Please fill out completely PATIENT REGISTRATION: Name: Date of Birth: Age: Today s Date: First Middle Last Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: E-Mail: Sex: Male Female
PATIENT REGISTRATION INFORMATION
COLUMBIADOCTORS OPHTHALMOLOGY Edward S. Harkness Eye Institute - 635 W. 165 th Street, New York, NY 10032 880 3 rd Avenue 2 nd Floor, New York, NY 10022 Morgan Stanley Children s Hospital of New York 3959
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:
Date SSN: DOB: Patient Name. Address
IRMO EYE CENTER PATIENT INFORMATION Date SSN: DOB: Patient Name Address (Street) (City) (State) (Zip) Home Telephone Cell Phone Sex: M F Marital Status: Married Divorced Widowed Separated Single Employment
Denny Eye & Laser Center Kevin Denny, MD Young Choi, OD Joy Ohara, OD
Kevin Denny, MD Young Choi, OD Joy Ohara, OD PATIENT REGISTRATION NAME: ADDRESS: SEX: male female LAST FIRST MIDDLE INITIAL NO. AND STREET CITY STATE ZIP ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL
TENNESSEE LASIK LASIK PATIENT INFO PACKET. clipboar. Privacy Practices. Patient Information. Medical History Questionaire
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PATIENT INFORMATION (please print) Name: also known as: Date of Birth: SS# M F Address:
PATIENT INFORMATION (please print) Name: _ also known as: _ of Birth: _ SS# M F Address: Home: ( ) Cell: ( ) Work: ( ) Other: ( ) Email: Referring Doctor: Practice: INSURANCE Primary Insurance: Policy
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
Dr. Joseph J. Timmes, Jr., M.D.
EYE HISTORY Name: Date: Thank you for choosing our office for your eyecare. To better serve you, please answer the following questions: 1. Do you wear glasses? YES NO 2. Do you wear contact lenses? YES
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.
Welcome to Biltmore Eye Physicians! Enclosed in our new patient packet are the following items: 1. Patient Registration 2. Credit Policy and Financial Agreement 3. Notice of Privacy Practices 4. Medical
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
Patient Registration Form
Patient Registration Form Name: Last First MI Today s Date: Address: Street City State Zip Phone: Best # Daytime # Cell # Date of Birth: Male Female Occupation: Employer: Social Security #: Email: Spouse
Patients who are running 20 minutes late for his/her scheduled appointment will be rescheduled to the next available appointment/ day.
Orthotics/ Durable Medical Equipment Policy H2T is NEVER able to guarantee payment by medical insurance carriers for Orthotics and/or Durable Medical Equipment. H2T will bill your medical insurance as
Welcome to Kapolei Eye Care
Welcome to Kapolei Eye Care NN Paper Acct#: PLEASE COMPLETE ALL PORTIONS OF THE THIS FORM (FRONT AND BACK) AS BEST AS YOU CAN PATIENT INFORMATION (Please provide your picture ID to the receptionist to
Welcome to the Aker Kasten Eye Center!
ALAN B. AKER, MD ANN G. KASTEN AKER, MD JILL F. RODILA, MD VITO J. GUARIO, OD KELLI F. WOLPER, OD Welcome to the Aker Kasten Eye Center! On behalf of the doctors and staff, we would like to thank you for
Name Date of Birth / / LAST FIRST MI NICKNAME Address Sex Male Female Age STREET NAME Social Security Number CITY STATE ZIPCODE
PATIENT HISTORY AND INFORMATION DATE Name of Birth / / LAST FIRST MI NICKNAME Address Sex Male Female Age STREET NAME Social Security Number CITY STATE ZIPCODE Home Telephone Work/Cell Telephone of Last
MEDICAL FORM (Please Fill in all Information)
MEDICAL FORM (Please Fill in all Information) Last Name First M.I. Spouse/Parent Name Home Phone Business or Cell Phone Home Address City and State Date of Birth Zip Code Sex M F Social Security # E-Mail
Patient Demographic Information
Patient Demographic Information Write your name as it appears on your insurance card. Please complete this form in its entirety Name: Male Female Date of Birth: Primary Insurance: Secondary Insurance:
Nicole A. Mueller, D.O., FAOCO Board Certified Ophthalmologist
1201 Medical Plaza Court Granbury, Texas 76048 ph. 817-279-9044 fax 817-573-6234 granburyeyeclinic.com Dear Patient: Thank you for placing your trust in us to provide your eye healthcare needs. Your appointment
Name Today's Date Sex / / Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com www.2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs.
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
Patient Information Sheet
Patient Information Sheet Welcome to our office. Please complete this form and return it to the receptionist. Please have all of your insurance cards ready to be copied. Patient Name Last First Middle
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
ADDRESS: CITY: STATE:
PATIENT INFORMATION FORMS (JUNE 2016) PATIENT INFORMATION: (PLEASE PRINT) WHO SHOULD WE THANK FOR REFERRING YOU TO OUR OFFICE? PATIENT FULL NAME: MARITAL STATUS: GENDER: SINGLE DIVORCED MALE MARRIED WIDOWED
Payments for co-pays and other fees are expected at the time of visit and will be collected upon checking out with the receptionist.
Marguerite R. Billbrough, MD Medical Director, Eye Physician & Surgeon The Ridley Professional Building, 1553 Chester Pike, Suite 101, Crum Lynne, PA 19022 Tel: 610-522-2822 Fax: 610-522-2880 Welcome to
Registration Form M F M F. None Full Time Part Time Retired Student. None Full Time Part Time Retired Student. Phone # EMERGENCY CONTACT.
Registration Form PATIET IFORMATIO Please use full legal name, no nicknames Last ame First ame Social Security # Address Sex City Home Phone # of Birth M.I. Cell Phone # Marital Status Preferred contact
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 (
Ronald E. McFarland M.D. PATIENT REGISTRATION AND HISTORY
Ronald E. McFarland M.D. 2021 Church Street, Suite 606 Nashville, TN 37203 PATIENT REGISTRATION AND HISTORY Date: Primary Care Doctor: Name: Sr. Jr. Address: Street City State Zip Code Telephone: Home
COREY M. NOTIS, M.D., P.A.
COREY M. NOTIS, M.D., P.A. Registration Form Last Name: First Name Address: City: State: Zip Code: Home Phone: Work Phone Cell Phone: Date of Birth: Social Security # Emergency Contact Name: Phone #: Occupation:
Street Address: Apt. # City State Zip. Employer Name and Address. City State Zip. Name of Spouse or Guardian. Emergency Contact Name and Phone
Patient Name Social Security Number: Date of Birth: Age: Street Address: Apt. # City State Zip Home Phone: ( ) -- Mobile Phone: ( ) -- Employer Name and Address City State Zip Business Phone ( ) -- Occupation
Arizona Retina Associates
PATIENT INFORMATION PLEASE PRINT CLEARLY AND COMPLETE ENTIRE FORM Name FIRST MIDDLE INITIAL LAST SUFFIX (Jr., etc.) Address STREET CITY STATE ZIP Age Birthdate SS# Marital Status S M D W Sex M F Occupation
PATIENT REGISTRATION **PLEASE PRINT** LAST NAME FIRST NAME MI. Date of Birth Age SS#
PATIENT REGISTRATION of Birth Age SS# Primary Physician Previous Eye Doctor How did you hear about us? q Yellow Pages q Church Bulletin q Advertisement q Internet q Friend/Family q Referring Doctor Patient's
Insuring Your Eye Health in Ohio
Insuring Your Eye Health in Ohio Most people require some kind of eye care throughout their lifetime, but how do they pay for it? Insurance can be a confusing topic in any circumstance but this is especially
MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED GENDER: MALE FEMALE
- PATIENT INFORMATION: (PLEASE PRINT) WHO SHOULD WE THANK FOR REFERRING YOU TO OUR OFFICE? PATIENT FULL NAME: CURRENT AGE MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED GENDER: MALE FEMALE ADDRESS: CITY:
Insuring Your Eye Health
Insuring Your Eye Health Most people require some kind of eye care throughout their lifetime, but how do they pay for it? Insurance can be a confusing topic in any circumstance but this is especially true
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
record of mental health or substance abuse treatment
Limited Patient Authorization for Disclosure of Protected Health Information (PHI) Please print all information. Form must be signed and dated each year. Patient Name: Account #: Social Security Number:
Address Who referred you to our practice? relationship
Health History Form Date Name Home Phone ( ) Cell ( ) Work ( ) Address City State Zip Code Occupation Height Weight Date of Birth Sex M F SS# Emergency Contact Relationship Phone ( ) E-mail Address Who
Patient History Information Fill in all the blanks. Date and Sign on the back. Patient Information Name: (Last) (First) (Middle)
dba AND OPHTHALMOLOGY ASC, LLC and VAN DYCK ASC, LLC Date completed: Patient Information Name: (Last) (First) (Middle) Address: City: State: County: Zip Code: Sex: Race: Email: Date of Birth: Age: Social
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
ROBERT H. OLIVER, M.D., PLLC Otolaryngology Head And Neck Surgery Otolaryngic Allergy Chart #
Chart # PATIENT INFORMATION Please Print, Complete Fully, And Return To The Front Desk Circle One: Mr. Mrs. Ms. Miss. Dr. Child Please Circle: Sex: Male Female Marital Status: S M Other Widowed Patient
MannEye.com 1(800)MY-VISION
MannEye.com 1(800)MY-VISION Medical History Questionnaire 6 9 8-4 7 4 6 Name: Date of Birth: Date: Height: Weight: Do you wear contacts or glasses? Yes No Type: List any medications you currently take
On the Day Of Your Appointment You Will Need To Bring The Following:
Please complete all patient information forms attached. To better assist you in a timely manner, to guarantee communication with your referring and primary care physicians and to properly care for you,
Dear Patient, Welcome to Family Eye Center Optometry, where we do things differently. We want to thank you for choosing us for your eye health care. We value your confidence in us and want to let you know