Patient Registration Form Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.***We recommend using Google Chrome when filling out our online forms!Patient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Please provide a telephone number, with area code, so we can contact you.Daytime PhoneCell PhoneEmail AddressPlease provide us your email address.COVID Questions (required)Have you been out of state in the last 14 days?*YesNoHave you had a temperature or COVID like symptoms in the past 14 days?*YesNoHas a family member or anyone in your household had COVID like symptoms?*YesNoHas a family member or anyone in your household tested positive for COVID?*YesNoPersonal InformationGender*FemaleMaleNon-BinaryTransgenderIntersexI prefer not to sayPreferred PronounsDate of Birth* Date Format: MM slash DD slash YYYY Social Security Number (last 4 digits only!)Preferred Language*Select Preferred Language >EnglishSpanishFrenchJapaneseDecline to specifyRace*Select Race >American Indian or Alaska NativeAsianBlack or African AmericanHispanicNative Hawaiian or Pacific IslanderWhiteDecline to specifyEthnicity*Select Ethnicity >Decline to specifyHispanic or LatinoNative Hawaiian or other Pacific IslanderNot Hispanic or LatinoMarital StatusSelect Marital Status >DivorcedLegally SeparatedMarriedSingleWidowedPartnerOtherMarital Status - OtherPlease provide your marital status.Employment StatusSelect Employment Status >Employed Full-TimeEmployed Part-TimeNot EmployedOn Active Military DutyRetiredSelf-EmployedStudent Full-TimeStudent Part-TimeOtherEmployment Status - OtherPlease provide your employment status.EmployerOccupationHow were you referred to our office?Select Referral Type >Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherReferral Status - OtherPlease let us know how you were referred to our office.Communication PreferenceSelect Communication Preference >EmailPostalTelephoneEye HistoryPlease check off any current conditions you suffer from I stopped wearing glasses I stopped wearing contact lenses Headaches Glare/Light Sensitivity Tired Eyes Amblyopia (lazy eye) Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping eyelid(s) Redness Sandy or Gritty Feeling Strabismus (crossed eye) Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision I stopped wearing glasses because:I stopped wearing contact lenses because:Glasses HistoryDo you wear glasses?*YesNoWhat glasses do you own? Single Vision Bifocals Safety Glasses Backup Glasses Progressive Trifocals Sports Glasses Sunglasses Other Other glasses:Please tell us what other kinds of glasses you own.How many hours a day do you use a computer?Please enter a number from 0 to 24.How many inches away, approximately, do you sit from your computer monitor?Please enter a number from 0 to 120.Please check off any current conditions you suffer from I am having problems with my current glasses There are times when I would rather not be wearing glasses I have problems with glare I have problems with night vision I am allergic to nickel (e.g. frames of glasses) I don’t have spare set of glasses My spare glasses have an incorrect prescription My sunglasses are missing UV (ultra-violet) protection Contact Lens HistoryDo you wear contact lenses?*YesNoWhat brand of contact lenses do you wear?How old are your current lenses?How often do you replace or dispose your contact lenses?What brand of solution do you soak your lenses in?What is your typical wearing schedule? In hours per day:Please enter a number from 0 to 24.What is your typical wearing schedule? In days per week:Please enter a number from 0 to 7.Please check off all that apply to you I am having problems with my current contact lenses There are times when I would rather not be wearing contact lenses I am interested in changing or enhancing my eye color I am interested in a non-surgical method of vision correction I am interested in refractive laser surgery I don't have a spare set of contact lenses My spare contact lenses have an incorrect prescription Medical HistoryWhen, approximately, was your last eye exam?Where did you get your last eye exam?When, approximately, was your last physical exam?Who is your primary care physician?Do you drink alcohol?Do you drink alcohol >NoYes, 1 per weekYes, 1 per dayYes, 2 or 3 per dayYes, 4 or more per dayDo you smoke?Do you smoke >NoYes, 1/2 a pack per dayYes, 1 pack per dayYes, more than 1 pack per dayPlease list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)Please list all hospital surgeries you have ever had:Please list all prescription and over-the-counter medications you take and for what conditionsPlease list all drug allergies you havePlease check off any current conditions you suffer from Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat) Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet) Respiratory problems (eg. Shortness of breath, wheezing, coughing) Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints) Skin problems (eg. Rashes, excessive dryness, growths or lumps) Neurological problems (eg. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (eg. Depression, anxiety) Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands) Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens) Primary InsurancePlease bring all insurance cards with you to your appointment.Insurance Company Name*<<Select>>VSPEyeMedDavis VisionSpecteraMarch Vision CareVBAHumana Vision - VCPMedicareSelf-PayInsured's Name* First Last Identification Number*Group Number*Insured's Date of Birth* Date Format: MM slash DD slash YYYY Patient's Relation to Insured*Secondary InsuranceDo you have secondary insurance?YesNoIf you have coverage through another plan/organization, please fill in the details below.Insurance Company Name<<Select>>VSPEyeMedDavis VisionSpecteraMarch Vision CareVBAHumana Vision - VCPOther (please contact the office)Insurance Company Phone NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Insured's Name First Last Identification NumberGroup NumberInsured's Date of Birth Date Format: MM slash DD slash YYYY Patient's Relation to InsuredCommentsIf you have any comments you would like to add, please enter them here.Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy Signature of Patient or RepresentativeFINANCIAL AGREEMENT STATEMENTROUTINE/MEDICAL/GENERAL POLICIES A copy of your insurance card(s) must be presented at time of service. Payment of your copay, co-insurance or deductible is due at the time of service. Eye exam, refraction and contact lens fit fees are due at the time of service and are non-refundable. All routine/yearly exams require a refraction to be performed as part of your visit. If we are billing your exam thru your medical insurance due to a medical diagnosis, we are required to collect the $30 fee in addition to your co-pay as this is not paid by any medical plan. Any referrals required by your insurance from your primary care doctor are due at the time of service. If you do not have one your appointment will need to be rescheduled. We accept cash, personal check, Care Credit and all major credit cards. There is a $35 non-refundable fee for any check returned from your bank. Balance bill payments are due within 30 days of payment from your insurance company. There is a $25 late fee assessed to any open balances after 90 days. Failure to show up for or to give at least a 24 hour notice that you will not be coming for your appointment may result in a $30 no show/cancellation fee that must be paid before booking any future appointments. There is a $25 non-refundable per form fee to fill out forms. Forms could include, but are not limited to, any insurance, FMLA, Worker’s Comp or other forms. This fee is due, plus postage if needing to be mailed, prior to filling out/mailing/faxing forms. OPTICAL & CONTACT LENS POLICIES Eyeglasses and contact lens payments are due at the time of order. No refunds will be given on eyeglass orders once they have begun processing at the lab or after dispensing. Any changes made may be subject to restocking fees. However, every effort will be made to address any concerns you may have. Any non-prescription materials (sunglasses, specialty computer glasses or readers) are returnable only for store credit within 7 calendar days under the condition they meet practice resale standards. All new and previous contact lens wearers will be charged a non-refundable annual contact lens evaluation fee, which ranges from $60 - $120+, or the amount dictated by your insurance company. This fee is in addition to the eye exam fee and is due at the time of service. This fee must be paid in order to issue a new/valid prescription for ordering purposes. By signing you agree that you have read and you agree to all of the terms listed above. By signing you also agree to be financially responsible for any and all of the charges incurred by you and not paid for by your insurance plan. You also agree that if for any reason your insurance company denies payment on services or materials that you are responsible for payment in full. If you have any questions regarding this policy or your visit, please ask to speak with the Practice Administrator prior to signing.Patient's Name First Last Signature of Patient or RepresentativeDate Date Format: MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
