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 PEDIATRIC HEALTH HISTORY Patient Name: DOB: Primary Doctor: Referring Doctor: Grade in school: Hobbies: Ethnic Background: Living with: (circle all that apply) Mother Father Grandparent Foster care Born: Full term Premature How many weeks? Birth weight: On Oxygen after birth? Yes No Where there any complications during the pregnancy or delivery? Medical History (circle all that applies and to whom) Amblyopia Strabismus Cataracts Glaucoma Retinal Detachment Corneal Transplant Blindness Ocular Trauma Diabetes Arthritis Thyroid Disease Blood Clotting Disease Asthma Cancer Hepatitis HIV or AIDS Other medical conditions not listed: Ocular or general surgeries: Current medications: Eye drops: Allergies to medications: Do you currently wear glasses? Yes No Do you currently wear contacts? Yes No What can we help you with today? (circle all that applies) Blurred vision Crusts / goopy Eye pain Lazy eye Double vision Headaches Light sensitivity Reading problems Eyes cross in Rubbing eyes Squinting Eyes drift out Itching School concern Watering eyes Redness Update glasses Interested in contact lens Other:
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
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
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! Dr.! Mr.! Mrs.! Ms.! Miss CHILDREN VISION QUESTIONAIRE For Patients aged Kindergarten-18 years Judson Family Vision Care Amanda Judson, OD, MS, FCOVD Phone: 812-232-1000 Fax: 812-232-1007 Date of Visit:
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Name (Last, First, MI): Date of Birth: / /
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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
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
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
ADVANCED VEIN & VASCULAR SOLUTIONS Board Certified Vascular Surgeons
ADVANCED VEIN & VASCULAR SOLUTIONS Board Certified Vascular Surgeons We would like to thank you for choosing Advanced Vein & Vascular Solutions for your care. We are committed to providing you with quality
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
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:
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 # (
SAGUARO SURGICAL PATIENT REGISTRATION FORM
Account # Date Patient Name: M F Last First Legal Nickname MI Is this your legal name? Yes No If no, what is your legal name? Marital Status: SAGUARO SURGICAL PATIENT REGISTRATION FORM Single Married Divorce
Last Name: First MI. Birthdate: Age: Sex: SSN: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:
604 W. Warner Road, Ste. B-6~ Chandler, AZ 85225 5301 S. Superstition Mountain Drive~ Gold Canyon, AZ 85118 Phone: 480-963-3881 Fax: 480-899-8610 Complete Medical & Surgical Eye Care for All Ages Thank
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE
Surgery Partners Affiliated Covered Entity (SPACE) 2018 ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I have received the attached Privacy Notice. PRINT PATIENT S NAME DATE OF BIRTH AGREEMENT
Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
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 CONSULTATION. List of your current medications and allergies. Insurance Cards and Vision Insurance Information
NEW PATIENT CONSULTATION Please bring all the following to your appointment along with the forms completed and signed. List of your current medications and allergies Insurance Cards and Vision Insurance
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
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
Patient Information. Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Address: Home Away Address: City: State: Zip:
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:
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
BRAMLETT ORTHOPEDICS
BRAMLETT ORTHOPEDICS 200 Montgomery Highway, STE 200 Birmingham, AL 35216 Patient Information Phone: 205-783-5900 Fax: 205-783-5906 Patient Information Name (Last, First, Middle) Social Security Number
Name: Date of Birth: Sex: Office: Date:
Patient Information Name: Date of Birth: Sex: Office: Date: Address: City: State: Zip: Social Security Number: Home Phone: Cell Phone: Email: May we leave a message? Email? Martial Status Emergency Contact