TALLAHASSEE EYE CENTER
|
|
|
- Owen Hampton
- 10 years ago
- Views:
Transcription
1 TALLAHASSEE EYE CENTER PATIENT INFORMATION Date: Name: Gender: M / F First MI Last Date of Birth: / / Address: City: State: ZIP: Phone Numbers: Home: Cellular: Work: SS#: - - What is the best way to contact you? Home Cellular Work Mail Other Race: (please circle) White / Black (African American) / Asian / Multiracial / Hispanic / Other Ethnicity: Hispanic (Latino) / Not Hispanic (Latino) / Native Hawaiian or Pacific Islander Preferred language: English / Spanish Occupation: Employer: Spouse s Name: Dependent Children s Name(s): Person to contact in case of emergency: Phone: How did you hear about our office? INSURANCE INFORMATION (please bring all insurance cards to receptionist) Primary Medical Insurance: Secondary Medical Insurance: Vision Insurance: AUTHORIZATIONS I acknowledge that I have received a copy of Tallahassee Eye Center s Notice of Privacy Practices. Patient Signature: Date: I authorize the release of any medical information necessary to process insurance claims to my insurance company and/or any other physician or health care provider that may be involved in my care. I authorize and request my insurance company to remit payment of benefits directly to Tallahassee Eye Center. I further understand that I am responsible for payment for all services rendered including those services that may not be covered by my insurance company. This authorization is to be valid until otherwise revoked in writing. Patient Signature: Date: The doctors at Tallahassee Eye Center routinely dilate the pupils of the eyes in order to obtain a thorough view of the interior structures of the eye. Without pupil dilation, the doctor will not be able to completely evaluate your eye health and may not detect certain diseases and disorders. Pupil dilation usually results in blurry near vision and increased light sensitivity for 3 to 6 hours. Although most patients have minimal effect upon their distance vision and feel comfortable driving after dilation, it is possible that you may not see well enough to drive safely. It is your responsibility to make arrangements to be transported by other means if you feel that your vision is too blurry to drive safely following dilation. It is also your responsibility to notify the doctor and staff if you do not wish to have your eyes dilated or would prefer to reschedule the dilation. I have read and understand the above statement regarding pupil dilation. Patient Signature: Date:
2 MEDICARE COVERAGE OVERVIEW For your convenience, our office is a participating provider with Medicare. This means that our office bills Medicare for your office visits, tests and materials. Medicare then reviews all submitted claims and if approved, reimburses our office 80% of the approved amount. The remaining 20% (the co-payment) is your responsibility as the Medicare beneficiary. You are also responsible for a deductible and certain non-covered fees, as described below. Our office may elect to 1) bill you directly for your portion of the fees, or 2) bill your supplemental insurance, if you carry it. MEDICARE HMO PLANS Tallahassee Eye Center is not a provider for any Medicare HMO plans (Advantage Plus, Universal, etc.) with the exception of Medicare Humana Gold. If you are a participant with any of these plans, you will be responsible for payment for your services and materials. We will be happy to provide you with the paperwork you will need to supply your insurance company for any appropriate reimbursement. DEDUCTIBLE Medicare has a yearly deductible ($147 in 2013) that takes effect each January and may change from year to year. If our office is the first to submit a Medicare claim for you in the current calendar year, Medicare will notify you that you have not met your deductible for the year. Medicare will not pay for your allowable fees until the deductible is met. EXCEPTIONS, NON-COVERED SERVICES & MATERIAL FEES Medicare does not pay for refractive services. This is the part of your eye exam that determines your prescription for eyeglasses. It is typically performed on a yearly basis. Medicare will not pay for any services unless there is a medical reason for the visit. Preventative medical services and screenings are not covered by Medicare. If your exam is purely routine (to determine your eyeglasses prescription and screen for eye disease) and no separate medical diagnosis is made, Medicare will not cover any fees for that visit. Medicare does not cover glasses or contact lenses unless you have had cataract surgery. If you have had cataract surgery, Medicare will cover a portion of the cost of your eyeglass lenses and one standard frame one time per operation. Any additional lens options or frame upgrades are your responsibility. AUTHORIZATION STATEMENT/SIGNATURE I have read and understand the information above and agree to pay for any services and materials I order, but which are not covered by Medicare. Patient/Beneficiary Signature Date LIFETIME INSURANCE SIGNATURE ON FILE I certify that the information given by me in applying for the insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly to Tallahassee Eye Center on my behalf for any services and materials furnished. I authorize and 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 to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as my agent, as above. Lifetime Patient Signature Date
3 Screening Retinal Photography Tallahassee Eye Center is now offering a new, computerized digital camera that allows us to provide you with a more thorough medical analysis of your eye health. This digital retinal imaging system takes high resolution photographs of your retina (the back of your eye) to assist your doctor in the early detection of many disorders including cataracts, macular degeneration, glaucoma, diabetic retinopathy and many other conditions. These images are stored in the computer and will be compared with images acquired during future exams to allow the doctor to observe even the smallest change from the previous exam. Screening retinal photography is strongly recommended for: Patients who are new to our practice Patients who have never had retinal photos in this office (we recommend screening retinal photography every 1 to 3 years depending on risk factors) Patients over 65 years of age Patients with a family history of diabetes, high blood pressure, glaucoma or macular degeneration Patients who have vision that is not correctable to 20/20 in one or both eyes The fee for screening retinal photography is $28, and is not typically covered by your insurance. Dilation is usually not required to obtain screening retinal photographs. YES, I want this procedure NO, I do not want this procedure Signature Print name Date Extended Retinal Photography We also are able to perform extended retinal photography for patients with certain eye conditions. Extended retinal photography is strongly recommended for: Patients with ocular conditions such as glaucoma, diabetic retinopathy, macular degeneration and others. Your doctor will advise you if you need extended retinal photography. The fee for extended retinal photography is $82 and is typically covered by your medical insurance after all deductibles and co-payments have been made.
4 MEDICAL HISTORY Please Print Patient s Name Ocular History Date / / Date of Last Eye Exam: Who was your prior eye doctor? Do you wear glasses? No Yes If yes, how old is your present pair of lenses? Do you wear contact lenses? No Yes If yes, how old is your present pair of lenses? Brand and power of current contact lenses: If you do not already wear contacts, are you interested in wearing contact lenses? Yes No Have you ever been diagnosed with any of the following? Disease/Condition NO YES Disease/Condition NO YES Additional information: Cataracts Dry eye Glaucoma Corneal disease Diabetic retinopathy Retinal disease Eye Injury Lazy eye - amblyopia Please list any prior eye surgeries (including dates): Please list any eye-related medications (including over-the-counter) that you use: Medical History Primary Care Provider Last Visit / / Phone ( ) Are you pregnant and/or nursing? No Yes Do you have any allergies to medications? No Yes If yes, explain: Have you ever been diagnosed with any of the following? Disease/Condition NO YES Disease/Condition NO YES Disease/Condition NO YES High blood pressure Rheumatoid Arthritis Infectious disease Heart disease Lupus Kidney disease Diabetes Thyroid disorder Liver disease Breathing problems Cancer Other List all major injuries, surgeries and/or hospitalizations you have had: Medications (include dosages): Social History Do you drive? No Yes If yes, do you have visual difficulty when driving? No Yes Do you use tobacco products? No Yes If yes, type/amount/how long: Do you drink alcohol? No Yes If yes, type/amount/how long: Do you use illegal drugs? No Yes If yes, type/amount/how long:
5 Family History Please note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions: Blindness Disease/Condition NO YES? Relationship to You Crossed Eyes Cataract Glaucoma Macular Degeneration Retinal Detachment/Disease Heart Disease High Blood Pressure Diabetes Other Review of Systems Current Vital Signs: Height: Weight: Do you currently have any problems in the following areas? ALLERGIC Environmental allergies CARDIOVASCULAR Chest pain/pressure Irregular heartbeat CONSTITUTIONAL Fevers Unexplained weight loss/gain EAR, NOSE, THROAT Dry throat/mouth Chronic congestion Hearing loss ENDOCRINE Blood sugar variations Excessive thirst/urination EYES Blurred vision Loss of vision Double vision Dryness Itching Sandy/gritty/foreign body sensation Excessive watering/tearing Discharge Glare/light sensitivity Eye pain/soreness Chronic eye infection Flashes Floaters NO YES? NO YES? GASTROINTESTINAL Nausea/vomiting Diarrhea/constipation Abdominal pain GENITOURINARY Urinary difficulties HEMATOLOGIC Unusual bleeding Easy bruising IMMUNOLOGIC Autoimmune disorder Infectious disease INTEGUMENTARY Skin lesions/rashes/mass Changes in skin pigmentation MUSCULOSKELETAL Unexplained muscle/joint pain NEUROLOGICAL Stroke Seizure Numbness/tingling PSYCHIATRIC Anxiety Depression Mood swings RESPIRATORY Shortness of breath Chronic cough If you answered YES to any of the above or have a condition not listed, please explain:
PRE-EXAM QUESTIONNAIRE
Matthew T. Stanley, O.D. Darcy D. Stanley, O.D. Doctors of Optometry Patient #: PRE-EXAM QUESTIONNAIRE Name: Sex: M F Today s Date: / / Name you prefer to be called: Home Phone: Street Address: Daytime
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork.
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork. So we may eliminate any potential waiting time, please fax the completed forms
Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600
PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: [email protected] Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)
THE EYE INSTITUTE. Dear Patient:
THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0464 Eye Institute North, LLC 5677 Berkshire Valley Rd. Oak Ridge, NJ 07438 p. 973-208-0600
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
Eye Care of Delaware Patient Health Questionnaire
Eye Care of Delaware Patient Health Questionnaire Name: Date of birth: Referred by: Eye doctor: Family doctor: Pharmacy name: Phone #: Pharmacy location: Reason for today's visit (signs/symptoms): When
Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:
Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405
19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405 Welcome to our practice. We are happy that you selected us as your eye care provider and appreciate the opportunity
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
Florida Eye Center Patient Registration Form (Please Print Clearly)
Florida Eye Center Patient Registration Form (Please Print Clearly) Personal Information Legal Name: Last First MI Suffix Nickname: Social Security: - - Drivers License # Date of Birth: / / Mailing Address:
Patient Demographic Sheet
Patient Demographic Sheet Patient Name: Date of Birth: Address: City, State, Zip Code: Home Phone: Cell Phone: Work Phone: E-Mail: Sex: Male Female Marital Status: Married Single Other Occupation: Employer:
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction this portion of the examination determines the best lens correction
INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION
PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
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:
PATIENT INFORMATION FORM. Name: Address: City: State: Zip: Social Security Number: Telephone Numbers Home: Age: Sex: M / F Work: Email: Cell:
PATIENT INFORMATION FORM Name: Address: City: State: Zip: Social Security Number: Telephone Numbers DOB: Home: Age: Sex: M / F Work: Email: Cell: Marital Status: Single Married Spouse s Name: Widowed Divorced
Ophthalmology Associates of the Valley
Patient Name: Date: Ophthalmology Associates of the Valley Patient History Record Please answer the following questions about your medical status and history: 1. Your reason for today s visit. Briefly
Please Print. Patient Name Last First Middle. Address Street Apt # City State Zip. Date of Birth Gender. Home Phone Cell Phone
Please Print Patient Name Last First Middle Address Street Apt # City State Zip Date of Birth Gender Home Phone Cell Phone Work Phone Social Security# E-mail Occupation Employer Spouse s Name Phone Referred
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:
PATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.
Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
CORONADO EYE ASSOCIATES GLENN B. COOK, M.D., PhD 801 ORANGE AVENUE, STE. 204 - CORONADO, CA 92118 619.437-4406 FAX 619.522-7983
Dear Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible. Enclosed is your patient information sheet and medical history questionnaire. Please
Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 [email protected] www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
WELCOME TO COPPELL VISION CENTER
WELCOME TO COPPELL VISION CENTER Please Print Name Address Sex: Male Female City/State/Zip Age Home Phone of Birth Alternate Phone SSN# Profession Employed By Responsible Party Address and Phone Number
PATIENT DEMOGRAPHIC SHEET
Patient Information PATIENT DEMOGRAPHIC SHEET Last Name First Name MI of Birth Age Social Security Number Married Widowed Single Other: Marital Status Occupation/Retired Employer English Spanish Mail Phone
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
Eger Eye Group, P.C.
Eger Eye Group, P.C. Last Name: Middle Initial: First Name: Birth Date: Street Address: City/State/Zip: Home Phone: ( ) Work Phone: ( ) Email: Occupation: Employer: Soc. Sec. #: Age: Sex: M F Race: Accompanied
ORANGE COUNTY EYE INSTITUTE
ORANGE COUNTY EYE INSTITUTE *Note: It is the patient s responsibility to file insurance claims if we are not contracted with your insurance company. *Note: Be aware that most medical insurance plans do
RETINA CARE CENTER, P.C. PATIENT INFORMATION
RETINA CARE CENTER, P.C. JONATHAN M. BAROFSKY, M.D., F.A.C.S. Parkway Seventy Plaza 1255 Route 70, Suite 31N Lakewood, New Jersey 08701 PHONE (732)905 0004 FAX (732)905 3868 PATIENT INFORMATION Welcome
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible.
PAUL L. TREGER, M.D. RANDALL CONRAD, O.D. GLENN B. COOK, M.D., PhD TARA BROWN, M.D. 7877 PARKWAY DRIVE SUITE 100 - LA MESA, CA 91942 619.286.3711 FAX 619.286.2184 Dear Please allow us to welcome you to
MEDICAL & OCULAR HISTORY QUESTIONAIRRE
MEDICAL & OCULAR HISTORY QUESTIONAIRRE Name: Date: Age: Preferred Pharmacy Name: Address: 1. Please describe briefly the main reason you are being examined today. 2. Do you have any of the following conditions
How to Remove a Social History Smoke?
AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
MEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day
MEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day PATIENT REGISTRATION CONFIDENTIAL PLEASE COMPLETELY PRINT THE FOLLOWING AND SIGN BELOW PATIENT INFORMATION
Please bring the following with you to your appointment: Completed New Patient forms A list of all prescribed medications with dosages and quantity
Mark E. Hollingshead, M.D. Cataract & Refractive Surgeon Welcome: We look forward to being of assistance to you on your first visit with Hollingshead Eye Center. In order to provide the best possible service,
Physician address. Physician phone
PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center www.michigansportsmedicine.com Your family physician
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com 1 Calvin E. Mein, MD 9480 Huebner Rd, Suite 310 (210) 615-1311 Moises A. Chica, MD San Antonio,
IMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465
THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465 Dear Patient: Welcome to the Eye Institute. Our mission is to provide you with the highest
Personal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer
Colorado Cataract & Laser, LLC The Center for Eye Care Excellence
Colorado Cataract & Laser, LLC Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma Dear Patient: Thank you for selecting Colorado Cataract & Laser, LLC
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
Emory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions
Your appointment is scheduled for at with Dr. Your arrival time is.
Dear : We appreciate your selection of our office for your complete eye care. Your appointment is scheduled for at with Dr. Your arrival time is. First visits usually take approximately one and a half
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
Orthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11
PATIENT REGISTRATION 3.11 Last Name: First Name: MI: Local Address: City: State: Zip Code: DOB: Sex: Marital Status: Race: SSN [Required for reporting to Agency for Health Care Administration]: Were you
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
P.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
Orthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
The Eye Care Center of New Jersey 108 Broughton Avenue Bloomfield, NJ 07003
The Eye Care Center of New Jersey 108 Broughton Avenue Bloomfield, NJ 07003 Dear Patient, Welcome to The Eye Care Center of New Jersey! It means a great deal to us that you have chosen us to serve as your
Princeton and Rutgers Neurology, P.A. A Center Of Excellence
DEMOGRAPHICS Patient s Last Name: First Name: Address: City: State: Zip Code: Tel # (Cell): Tel # (Home): Tel # (Work) #: Preferred Method Of Contact: [] Cell Phone [] Home Phone [] Work Phone SS #: /
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address
OrthoVirginia Registration Information 2016
OrthoVirginia Registration Information 2016 Patient Information Patient Name Account # Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex Male Female City, State
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT
Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex:
(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Today s Date:
Page 1 of 5 (Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Age: What is the main reason for today s visit? Today s Date: Who referred you to
PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
RALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
FAMILY CONTACT INFORMATION
FAMILY CONTACT INFORMATION -------------------- PLEASE COMPLETE THIS FORM IN BLACK INK ONLY -------------------- Date Account # Children Names DOB Gender School Goes By Cell Phone # Email Address Please
Pulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
PATIENT/PARENT/GUARDIAN SIGNATURE
PATIENT REGISTRATION PATIENT S NAME: SEX MALE FEMALE DOB: SOCIAL SECURITY #: CITY/STATE/ZIP: PHONE # GUARANTOR INFORMATION (if responsible party is not the patient) MOTHER S NAME: DOB: SS#: CITY/STATE/ZIP:
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
Your appointment is scheduled for at.
2300 California St., Suite 300 San Francisco, CA 94115 Lee K. Schwartz, M.D. Thomas M. Swift, O.D. Margaret P. Liu, M.D. Tel: 415-921-7555 Fax: 415-921-1475 www.pacificeyespecialists.com Dear Patient:
PATIENT INFORMATION FILL OUT ALL ITEMS
PATIENT INFORMATION FILL OUT ALL ITEMS FAILURE TO COMPLETELY FILL OUT THIS FORM MAY RESULT IN YOU BEING BILLED IN FULL Patient Last Name: First: MI:. Address:. Date of Birth: Gender: M or F Marital Status:
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
Westoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province: