PATIENT REGISTRATION INFORMATION

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1 COLUMBIA OPHTHALMOLOGY CONSULTANTS 635 W. 165 th Street, New York, NY rd Avenue 2 nd Floor, New York, NY Prospect Avenue, Ridgewood, NJ PATIENT REGISTRATION INFORMATION Date: MR#: Date of Birth: Age: Last Name: First Name: Middle Initial: Gender: Male Female Address: Apt#: City: State: Zip Code: Home Phone: Cell Phone: Marital Status (circle one): Single/Married/Div./Sep./Widowed Spouse s Name (if applicable): Mother s First Name: Father s First Name: Employer: Occupation: Business Address: Business Phone: Primary Care Physician: Phone: Address: Pharmacy Address: Phone: Referred by: In case of emergency, who should we contact? Phone: Workman s Compensation: No Fault: PRIMARY INSURANCE: Person responsible for account: Phone: Relationship to Patient: Date of Birth: Address (if different from patient): Ins. Company: Ins. Company Address: Subscriber ID#: Group #: Co-pay: $ ADDITIONAL INSURANCE: Person responsible for account: Phone: Relationship to Patient: Date of Birth: Address (if different from patient): Ins. Company: Ins. Company Address: Subscriber ID#: Group #: Co-pay: $ Signature of Responsible Party: Date:

2 Columbia Ophthalmology Consultants Patient Medical History Questionnaire PATIENTN~.DOB: ALLERGIES: SENSITIVE TO: SOAPS? (1YES [1NO TAPES? (J NO OTHER WOMEN, ARE YOU PREGNANT? [ ] NO DO YOU EVER TAKE ASPIRIN, PLAVIX, COUMADIN, LOVENOX []YES [] NO EYE OR EYELID RELATED PROBLEMS: [] NO [] Glaucoma [] Strabismus / crossed eyes [ ] Thyroid eye disease / Graves' disease [ ] Retinal detachment [ ] Macular degeneration [ ] Eye inflammation ( J Droopy eyelids [ IAmblyopia / "lazy eye" [ ] Eye injury [] Dry eye [ ] Double vision [ ] Tearing [ ] Other [] Previous eye surgery? What kind(s) [ ] Previous face, brow, eyelid, tear duct, or orbital surgery? What kind(s) [] Previous cosmetic facial procedures? (Botox, fillers, peels, LASER, etc.) What kind(s) SYSTEMIC PROBLEMS: [ ] NO [ J Fevers [ 1Night Sweats [] Unexplained weight loss [] Fatigue EAR, NOSE OR THROAT PROBLEMS: [] NO [ ] Hearing loss [] Chronic Allergies [] Sinusitis CARDIOVASCULAR PROBLEMS: [] NO [ ] High blood pressure [ ] Heart attack (MI) [] Angina (chest pain) [] Congestive heart failure [ ] Heart valve disease / murmur [ ] Pacemaker [ ] Blocked circulation to extremities or to carotid arteries RESPIRATORY PROBLEMS: [] NO [ ] Asthma [ ] Emphysema [ ] Chronic cough [ ] Pneumonia [ ] Recent respiratory infection [ ] Shortness of breath [] Dry Mouth [ ] Coronary artery disease [] Irregular heart rhytlun / Atrial fibrillation (] Other [ ] Chronic bronchitis [ ] Tuberculosis [ ] Home oxygen use GASTROINTESTINAL / ENDOCRINE PROBLEMS: [] NO [ ] Diabetes [ ] Thyroid disease [ ] Inflammatory Bowel Disease CLOTTING DISORDERS: [] NO [ ] Current anticoagulant therapy [ ] Bruise easy or frequent nose bleeds MUSCLE, JOINT, OR NERVE DISEASE: E] NO [ ] Arthritis [] Chronic back or neck pain [ ] Stroke [ ] Seizure disorders [ ] Dementia or Alzheimer's [ ] Fibromyalgia BLADDER/KIDNEY PROBLEMS: [] NO [] Frequent infections [] Incontinent of urine HISTORY OF SLOW OR POOR WOUND HEALING HISTORY OF COLD SORES. HERPES, SHINGLES HISTORY OF KELOIDS HISTORY OF SKIN CANCER HISTORY OF OTHER CANCER(S) HEPATITIS [] NO WHEN? POSITIVE HIV TEST: [ ] NO WHEN? Type: [] Currently taking Coumadin, Aspirin, Lovenox [ ] Lupus / SLE [ ] Psychiatric illness [] Kidney Failure requiring dialysis [] NO A TYPE: TYPE: B PROBLEMS TOLERATING ANESTHESIA: TO LOCAL ANESTHETIC [ ] NO TO GENERAL ANESTHETIC [ ] YES [] NO FAMILY HISTORY: GLAUCOMA THYROID DISEASE [ ] YES [] NO [ ] NO MACULAR DEGENERATION OTHER EYE CONDITIONS? SOCIAL HABITS: Smoking [ ] Never [] Past [] Current packs/ day Alcohol use [ ] Never [ ] Rare or Social [] Small Amount Daily [ ] Recovering alcoholism [] Chronic Current Use Drug use: [ ] Never [ ] Past [] Current CURRENT MEDICATIONS (including Supplements and Herbals): C [] NO Primary Care Physician: Telephone: Address: Preferred Pharmacy: Telephone: Remewedby: ~D

3 Columbia University Medical Center Columbia Ophthalmology Consultants Date: Name: Physician you are seeing today: In addition to our medical ophthalmology services, our physicians also specialize in laser refractive surgery (LASIK, Wavefront, PRK) and numerous aesthetic and rejuvenation procedures around the eyes. To ensure we are meeting our patient's needs, we ask that you complete the following questionnaire. Please check all that apply. These are the areas of interest or concern for me: D Laser refractive surgery (LASIK, Wavefront, PRK) D Droopy upper or lower eyelids D Excess skin on the eyelids D Droopy or angry appearing eyebrows D Bags under the eyes D Bumps or skin tags on the eyelids or face D Wrinkles and fine lines D Skin discoloration or hyperpigmentation D Dark circles or puffiness around the eyes D Desire for longer, fuller or darker eyelashes D Botox D Dermal fillers (Juvederm, Restylane, Radiesse) D None of the above concern me Do we have your permission to send information via /mail or call you regarding the above procedures and updates about our practice? DYes D No, please do not contact me address: Telephone number: How did you hear about us (please specify): D My physician: D A friend or family member: D Internet: D Other: Thank you! Patient Signature:

4 COLUMBIA OPHTHALMOLOGY CONSULTANTS \it) - COLUMBIA UNIVERSITY MEDICAL CENTER CONSENT FOR MEDICAL PHOTOGRAPHS Patient Name: D.O.B.: I,, give my consent to Columbia Ophthalmology Consultants, or any person designated by Dr. Bryan Winn to photograph me during the course of my treatment(s) in order to demonstrate my condition or disorder, subsequent therapy, including surgical procedures when I may be sedated or anesthetized, and the results of such therapy. I understand that such photographs will be treated as confidential except as authorized by me in writing. I agree that such photographs become the sole property of Columbia Ophthalmology Consultants/Columbia University and that they may dispose of them at any time. (please cross out any area in which you do not wish to participate). I further give my consent to Columbia Ophthalmology Consultants, or any person designated by Dr. Bryan Winn to use photographs of me for the following use: Scientific papers, publications in medical journals, medical and paramedical personnel trainings, and membership requirements for medical societies and certification boards. Promotional purposes (i.e. practice brochures, website, newsletters and external advertisements. I understand that at no time will my personal information and/or name be used. I waive all rights of publicity and release Columbia Ophthalmology Consultants and it's employed or contract photographers from liability with respect to reputable uses of my said photographic image and verbal testimonials for promotional purposes. I understand that this authorization is valid for all pictures taken during the course of my treatment(s). If at any time I wish to revoke this authorization I agree to notify Columbia Ophthalmology Consultants in writing of my wishes. SIGNATURE: DATE: WITNESS: DATE:

5 COLUMBIA OPHTHALMOLOGY CONSULTANTS AUTHORIZATION OF BENEFITS Name of Beneficiary: Health Insurance Claim #: I request that payment of authorized health insurance benefits, including Medicare and Medigap, be made either to me or on my behalf to Dr. for services furnished to me by this provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any information needed to determine these benefits payable for related services. Signature of Responsible Party: Date: Commercial Insurance I hereby authorize direct payment of surgical/medical benefits to Dr. for services rendered by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance, including co-pays, deductibles, refractions, and differences between surgeon s charges and allowable. I hereby authorize Dr. to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. Signature of Responsible Party: Date: Advance notice regarding Insurance Reimbursement and Beneficiary Agreement I have been informed that refraction (the measurement of one s eyeglass prescription and the determination of the best visual sharpness) is usually not considered by insurance companies, health maintenance organizations, and Medicare to be medically reasonable of necessary. Knowing this, I have instructed the doctor to proceed with the services. If insurance decides to reduce or even deny the fee or services, I agree to pay the doctor s fee in full. Signature of Responsible Party: Date:

6 Health Insurance Portability and Accountability Act (HIPAA) HIPAA Compliance/Columbia University Medical Center 601 West 168 th Street, Apt. #22, 2 nd Floor New York, NY 10032/ T(212) F(212) NOTICE OF PRIVACY PRACTICES DATE: ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I was provided with a copy of the Columbia University Medical Center Notice of Privacy Practices. Patient Name (Print) Patient Signature If completed by a patient s personal representative, please print and sign your name in the space below Personal Representative (Print) Personal Representative s Signature Relationship For Columbia University Medical Center use only. Complete this section if this form is not signed and dated by the patient or patient s representative. I have made a good faith effort to obtain a written acknowledgement of receipt of Columbia University Medical Center s Notice of Privacy Practices but was unable to for the following reason: Patient refused to sign Patient unable to sign Other Employee Name Date This form should be placed in the patient s medical record Revised October 2007

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