EyE CEntEr Paul V. Minotty, MD. Vision/Lifestyle Questionnaire. Name Date of birth
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- Colleen Newton
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1 /Lifestyle Questionnaire Date of birth In addition to gaining clearer vision after cataract surgery, patients today have more of a choice in their visual outcome. This is achieved by replacing the clouded natural lens of the eye with a new clear lens (IOL) that has prescription power specifically measured for the individual patient. Some lenses best correct at distance, some at near, some at both distance and near, and some for astigmatism. For these reasons, no one lens is right for every patient. Also, some lenses are an additional cost for the patient. Please help us to better understand your visual goals by answering the questions below. What is your occupation (present or former) and favorite hobbies? Have you ever worn contacts to correct one eye for distance and one eye for near? If yes, was it successful for you? Do you feel that dry conditions affect your vision? How do you feel about wearing glasses? (please check all that apply) I don't mind wearing glasses all day. I don't mind wearing glasses for reading /close work. I don't mind wearing glasses for TV/driving distances. I would like to greatly reduce dependence on glasses for both reading and far distance, even if there is an increased incidence of glare/halos and decreased contrast in certain lighting conditions. Would you be willing to pay an out-of-pocket expense for a lens that compensates for astigmatism, if needed? Would you be willing to pay an out-of-pocket expense for a lens that decreases some of your dependence on glasses for near/reading and far distances, if you are a candidate?
2 Frequently Asked Questions About Cataracts What is a cataract? A cataract is a clouding of the natural lens of the eye (which is located behind the pupil and iris). What causes a cataract? Though cataracts can occur at any age, most cataracts develop when aging or trauma cause proteins within the lens to break down and become cloudy or opaque. Less often, cataracts develop before birth, by use of corticosteroids, or by an inherited disorder. Prolonged exposure to sunlight and smoking may contribute to cataracts. Do cataracts ever go away on their own? No, the only treatment is surgery. Can cataracts be prevented? Though there is no certain prevention known, there are possible steps that a person could take in attempts to help prevent them. Wearing protective eyewear, when active, can aid against trauma. Wearing 100% UV protective sunglasses can aid against sun exposure. Avoiding smoking can aid in avoiding cellular oxidization. How fast do cataracts grow? There is a great variability. Some take years to change, while others change in a few months. Can cataracts develop in only one eye? Yes. How long does cataract surgery take? Generally minutes. Is anesthesia used for cataract surgery? Patients generally receive some sedation and the eye is numbed with eye drops. No needles are used and general anesthesia is not necessary. Are both eyes operated on the same day? No. The second eye is done when the first eye is safely out of the post-operative period. How long is the recovery time? This varies from a few weeks to longer in certain individuals. Normal activity generally resumes very shortly after surgery. Do cataracts come back after surgery? No, and the new lens stays clear. There is a normal clear membrane which is behind the lens called the posterior capsule. In some patients, the membrane may become cloudy in time. In this case, a simple laser procedure treats the cloudy membrane. Will my glasses be changed after surgery? Generally, yes.
3 VISION EYE CENTER ~ PATIENT INFORMATION SHEET PATIENT DEMOGRAPHICS Patient : Mailing Address: City: State: Zip: Street Address (if different from mailing): Primary Phone: Cell Phone: Patient Employer: Employer Phone: Address: Patient Date of Birth: Sex: M or F Marital Status: Patient SS #: Emergency Contact : Relation: Emergency Contact Phone: The information below is required for Electronic Medical Records: Pharmacy and Location: Preferred Language: Ethnicity: Not Hispanic or Latino Hispanic or Latino Race: Asian Black or African American White Other American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Which Doctor are you here to see? Dr. Minotty Dr. O Brien Dr. Tate Dr. Reinauer INSURANCE INFORMATION Primary Insurance: Secondary Insurance: Primary Cardholder and Date of Birth: (If Minor) Parents : Parents Date of Birth: Parents Daytime Phone: How did you hear about us? Please include names. Our Website Internet Search Radio Other Newspaper Screening Insurance Company TV Referred by M.D. Referred by Optometrist Referred by Friend/Family - Yes or No If yes, whom? DO NOT WRITE BELOW THIS LINE - FOR OFFICE USE ONLY Account Number: Date Registered: Registered By: Earning trust, one patient at a time.
4 Please read the following Payment Policies before your appointment. Our office files your insurance as a "courtesy" lf your Doctor is an in-network provider for your insurance, YOUR COPAY MUST BE PAID AT THE TIME OF SERVICE ALL DEDUCTIBLES ARE DUE AT THE TIME OF YOUR VISIT. Please note - Each insurance policy is different. It is your responsibility to know your policy. lf pre-authorization is needed, then it is your responsibility to notify our staff so we may obtain authorization. lf authorization is not obtained, it is your responsibility to pay for all charges incurred. Remember, your insurance policy is a contract between you and your insurance company. lt is not a contract between you and our Doctors. ln order for us to process your insurance, we must have a copy of the card. It is also your responsibility to let us know if there is a change in your insurance information. lf you have any questions or are not prepared to pay for your appointment, please notify one of our office staff prior to your appointment. lf you are unable to pay for residual balances from previous dates of service you may be asked to reschedule your appointment. There is a $10.00 charge for NSF checks. We do not participate with any HMO plans. *Self pay patients are expected to pay in full at time of service. Signature Print Date (By signing this document, I am stating that I have read and understand the above information)
5 Patient Consent Form for Use and Disclosure of Protected Health Information By signing this Consent Form, you give us permission to use and disclose protected health information about you for treatment, payment, and healthcare operations except for any restrictions specified below to which we have agreed. Protected health information is individually identifiable information we create or receive, including demographic information, relating to your physical or mental health, to provision of healthcare services to you, and to the collection of payment for providing healthcare services to you. Our Notice of Privacy Policies provides information about how we may use and disclose protected health information about you. As provided in our Notice, the terms of the Notice of Privacy Policies may change. If we change our Notice, you may obtain a revised copy by contacting our information privacy official, the Administrator, Lindy MacDonald at , who is also available to respond to any questions or receive any complaints you may have concerning your protected health information. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or healthcare operations. We are not required to agree to any restrictions, but if we do, we are bound to our agreement. If you wish to make a restriction, please request a copy of our Form to Request Restrictions. If you do not sign this Consent Form, we have the right to refuse you treatment unless a licensed healthcare professional has determined that you require emergency treatment or we are required by law to treat you. We are required to document any circumstances in which we do not obtain your consent, yet carry out treatment. We will offer you a copy of this documentation should you decide not to sign this Consent Form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. You may request to use our Authorization for Release of Information for purposes of requesting your revocation, or you may simply send us a letter in writing. By signing this consent, you acknowledge that you have received a copy of the "Notice of Privacy Policies". Please list the names of additional people we may disclose your protected health information either by phone or documentation: Patient s Signature Date
approximately 2-3 hours
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(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER
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PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:
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MacInnis Dermatology New Patient Registration Form Please print and answer all questions in full Date Patient Information (please complete using your name as listed on your insurance card) Patient First
Palos Pulmonary & Intensive Care Consultants Palos Sleep Center Michael Heniff, MD Jack Beaudoin, FNP
NAME: DATE: HOME PHONE: MEDICATION ALLERGIES 1. 2. 3. 4. 5. **Please list ALL of your current medications, strengths, and how you take your medication(s). (example: generic 30mg 1 time daily) 1. 2. 3.
PATIENT DATA SHEET PLEASE COMPLETE IN FULL AND SIGN
Patient ID Updated: 11/28/2017 PATIENT DATA SHEET PLEASE COMPLETE IN FULL AND SIGN Last Name: First Name: MI: Address: City: State: Zip: Home Phone: Cell Phone: Email: Second Address: From: To: City: State:
NAME: TODAY S DATE: PLEASE DRAW THE LOCATION OF YOUR COMPLAINTS BELOW, UTILIZING XXXXX FOR SYMPTOMS OF PAIN AND FOR NUMBNESS OR TINGLING:
NAME: TODAY S DATE: PLEASE DRAW THE LOCATION OF YOUR COMPLAINTS BELOW, UTILIZING XXXXX FOR SYMPTOMS OF PAIN AND 00000000 FOR NUMBNESS OR TINGLING: PLEASE GRADE YOUR PAIN INTENSITY BELOW: 0 10 No pain Worst
Patient Registration
Patient Registration Please check Primary Home Work Cell phone Gender SSN E-mail Address Driver s License M F Marital Status Preferred Contact Ethnicity Race Married Single Divorced Separated Widowed Life
SOUTH SHORE NEPHROLOGY, P.C.
SOUTH SHORE NEPHROLOGY, P.C. Please fill out this form along with all the documents included in the patient packet and bring it with you for your upcoming appointment. Be sure to bring your insurance card(s)
Annual Exam Welcome Back!
Annual Exam Welcome Back! Name: Date: An annual exam is preventative care consisting of a physical exam and possibly a Pap smear. If you have problems to discuss with the physician or nurse practitioner,
NARRA DERMATOLOGY AND AESTHETICS (425) Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields)
NARRA DERMATOLOGY AND AESTHETICS (425) 677-8867 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name Address Last First Middle Street & Apt
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 info@benjamineye.com www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
Mantonya Chiropractic Center LLC. New Patient Information Form (Please Print and complete all areas)
DR NP X-ray # Mantonya Chiropractic Center LLC New Patient Information Form (Please Print and complete all areas) Name Today'sDate Legal First Middle Last Mailing Address City State Zip Birth Date Age
Registration Information
Nevada Spine Center, LLC Registration Information Date Chart# D.O.B 10195 W. Twain Avenue Suite B Las Vegas, NV 89147 Patient Name SSN: Employer Drivers License # Required by the State of Florida Agency
West Cary Family Physicians 256 Towne Village Dr Cary, NC
New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s
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:
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:
REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:
: REGISTRATION FORM Physician (PCP): PATIENT INFORMATION Last Name: First Name: MI: Social Security #: DOB: Sex: M F Billing Address: City: ST Zip Code: Home Phone#:( ) Cell Phone#:( ) Work Phone#:( )
VASCULAR HEART & LUNG ASSOCIATES
PATIENT INFORMATION Last Name: First Name: M.I: Address: City: State: ZIP: Telephone (Cell): (Home): (Circle preferred contact method). Email: Date of Birth (MM/DD/YEAR): / / Age: Sex: SS# Ethnicity [circle]:
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last Name (Legal): First Name (Legal): MI: Preferred Name: Date of Birth: Social Security #: Marital Status: Sex Assigned at Birth: Single Married Widowed
Name: (Last) (First) (M.I.) Address: City: State: Zip Code:
WELCOME TO OUR PRACTICE information completely: 1. Patient Information: Social Security No: E-Mail Address: Name: (Last) (First) (M.I.) Address: City: State: Zip Code: Home Phone: Cell Phone: Date of Birth: