SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM

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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 OR EMAIL & 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:

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

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

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:

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

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