Patient Registration Online Form Name* First Middle Last 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 Date of Birth* MM slash DD slash YYYY Sex* M F SSN* Emergency Contact Emergency PhonePhysician’s Name Physician’s PhoneHome PhoneCell Phone*Work PhoneEmail Address HiddenDate MM slash DD slash YYYY Have you been to our office before? How did you hear about us? How can we make your visit the best you’ve ever had?What sports/hobbies do you enjoy? How many hours per day are you on the computer? Reason for today’s visit?Date of last exam? If you don't remember, please enter approximately how long ago like 1 year, 2 years ago, etc.Contact lens infoDo you currently use contacts?* Yes No What type? (select one in each row) Hard RGP Soft Disposable OrthoK Daily Bi-Weekly Monthly Sphere Toric/Astigmatism Bifocal Other Age of current contacts? Are you interested in getting contacts today? Yes No Glasses infoHow old are your current glasses? Are you interested in getting new glasses/contacts today Yes No Ocular Health: Questions regarding your eyes. 1. Have your eyes ever been dilated?* Yes No If so, How Long ago? 2. Have you ever had an eye infection, disease, injury, or surgery?* Yes No Explain 3. Are you unusually sensitive to light?* Yes No 4. Do you ever see double?* Yes No Explain 5. Do you have trouble with night vision?* Yes No 6. Do you have unusually frequent or severe headaches?* Yes No When and Where? 7. Do you have blurred vision?* Yes No When Do you have any of these dry eye symptoms? (check all that apply) Contact lens intolerance Redness Itchiness Stinging Burning Tearing Dryness Frequent Styes None of the above Medical Health Family History: Questions regarding your medical health and family history. Please Check All that apply Anyone in the family or yourself have been diagnosed with the following in the past or present.Diabetes Type I None Myself Father Mother Bro Sis Other Specify Diabetes Type II None Myself Father Mother Bro Sis Other Specify High Blood Pressure None Myself Father Mother Bro Sis Other Specify Thyroid Problems None Myself Father Mother Bro Sis Other Specify Cancer None Myself Father Mother Bro Sis Other Specify Heart Disease/Attack None Myself Father Mother Bro Sis Other Specify Kidney Trouble None Myself Father Mother Bro Sis Other Specify Respiratory Problems None Myself Father Mother Bro Sis Other Specify Liver Disease None Myself Father Mother Bro Sis Other Specify Psychiatric Care None Myself Father Mother Bro Sis Other Specify Hepatitis (A, B, C, D, E) None Myself Father Mother Bro Sis Other Specify Anemia None Myself Father Mother Bro Sis Other Specify Fainting/Dizzy Spills None Myself Father Mother Bro Sis Other Specify Other Please list any medication allergies Please list any other allergies Please list any medications you are currently taking and dosesSocial HistoryDo you drink alcohol ?* Yes No How much? Do you use tobacco?* Yes No How much? Do you use any other substances or recreational drugs?* Yes No What? Financial Agreement* I understand that all copayments, deductibles, or charges over the maximum benefit amount allowed by my insurance is due at the time of service.* I understand that all charges, regardless of insurance coverage, are ultimately the responsibility of the patient. If for any reason, payment is denied by my listed insurance company, the office will seek payment from me. Any benefits or pre-authorizations are not a guarantee of payment.* By signing below, I agree that I am financially responsible for any balance owed that is not covered by insurance. My signature also certifies that the information on this form is true and correct.Health Information Protection* I have read and agree to the Privacy Policy Signature of Patient or Party ResponsibleRetinal Photo ConsentWe recommend dilation every year with a comprehensive exam, however for patients who do not want to be dilated, photos are recommended. Dilation: Pros: Most comprehensive retinal evaluation. Dilation makes the pupil larger which gives us a better view of the retina. When the eyes are dilated we can see straight back which is where the nerve and macula are as well as far into the periphery of the eye. Cons: Dilation causes blurry vision up close for about 2-3 hours. Dilation will also make you light sensitive (we have disposable sunglasses in office to counteract this effect). Retinal Photos: Pros: You get to see inside of your own eye allowing you participate in your own care. There is a permanent record of exactly how your eye looks to compare year to year. Cons: We do not see as much area of the retina as with dilation.PLEASE SELECT ONE OF THE FOLLOWING OPTIONS* I authorize Advanced Eyecare Solutions to take Retinal photos instead of dilation. I understand there is $40 fee that is not covered by insurance. I do not want to be dilated today and refuse to get retinal photos taken as an alternative. I would like to be dilated today for a comprehensive health assessment. HiddenPLEASE SELECT ONE OF THE FOLLOWING OPTIONS* I authorize Advanced Eyecare Solutions to take Retinal photos instead of dilation. I understand there is $40 fee that is not covered by insurance. I do not want to be dilated today and refuse to get retinal photos taken as an alternative. I would like to be dilated today for a comprehensive health assessment. Signature
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