Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible.



Similar documents
CORONADO EYE ASSOCIATES GLENN B. COOK, M.D., PhD 801 ORANGE AVENUE, STE CORONADO, CA FAX

Patient Demographic Sheet

19235 N Cave Creek Rd #104 Phoenix, AZ Phone: (602) Fax: (602)

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.

NOTICE ABOUT REFRACTION

Insured Party Information (please complete if the insurance is not in your name)

Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone

PATIENT REGISTRATION

PATIENT REGISTRATION FORM PATIENT INFORMATION

THE EYE INSTITUTE. Dear Patient:

Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR Office: (503) Fax: (503)

Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous com

MEDICAL & OCULAR HISTORY QUESTIONAIRRE

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

New York Ophthalmology, P.C.

ORANGE COUNTY EYE INSTITUTE

LASIK/PRK Consultation

WELCOME TO COPPELL VISION CENTER

Please Print. Patient Name Last First Middle. Address Street Apt # City State Zip. Date of Birth Gender. Home Phone Cell Phone

TALLAHASSEE EYE CENTER

MEDICAL-SURGICAL EYE CARE, P.A.

Welcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear

Medical Insurance and Vision Plans

WELCOME TO OUR OFFICE

Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork.

Thank you for making an appointment with our office. We look forward to serving your visual needs.

PATIENT REGISTRATION FORM PATIENT INFORMATION

Dear Patient, We look forward to seeing you.

P.S. Please remember to bring your completed forms to your office visit!

Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:

Florida Eye Center Patient Registration Form (Please Print Clearly)

Cutting Edge Eye Care

Patient Intake Form. Patient Information. How did you find out about our office?

How Much Does a Cool Springs Eye Care Business Cost?

REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:

MEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day

WELCOME TO TRI-COUNTY EYE CLINIC

PATIENT/PARENT/GUARDIAN SIGNATURE

Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:

Please bring the following with you to your appointment: Completed New Patient forms A list of all prescribed medications with dosages and quantity

Are you interested in Laser Vision Correction/ LASIK? Yes / No

Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas Today s Date: How did you hear of our practice?

New Patient Information

PATIENT INFORMATION FORM. Name: Address: City: State: Zip: Social Security Number: Telephone Numbers Home: Age: Sex: M / F Work: Cell:

THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ p f

Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131

Welcome to Back Country Physical Therapy, Intake Form

Eye Care of Delaware Patient Health Questionnaire

PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:

PATIENT DEMOGRAPHIC SHEET

PATIENT REGISTRATION AND HISTORY FORM ~ FAMILY EYE HEALTH ASSOCIATES

We appreciate your selection of our office for your eye care.

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

William O. Reed, Jr. M.D., P.A W. 74 th Street, Suite 354 Overland Park, KS Fax:

Eger Eye Group, P.C.

PRE-EXAM QUESTIONNAIRE

RETINA CARE CENTER, P.C. PATIENT INFORMATION

The Eye Care Center of New Jersey 108 Broughton Avenue Bloomfield, NJ 07003

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information

Your appointment is scheduled for at.

Shelley Eye Center Welcome to Our Office

WACH Warfighter Refractive Eye Surgery Program WTU Application Form

INSURANCE VERIFICATION FORM - Atco Medical Associates

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI

Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (

PATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:

(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas NAME: Today s Date:

FAMILY CONTACT INFORMATION

Stanislaw Facial Plastic Surgery Center LLC Paul Stanislaw Jr., M.D.

North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip:

ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY (518) PATIENT INFORMATION FORM

PATIENT REGISTRATION INFORMATION

How To Contact A Doctor From A Doctor'S Office

Ophthalmology Associates of the Valley

Physician address. Physician phone

How To Get A Physical Therapy At West Point Physical Therapy Center

11120 New Hampshire Ave., Suite 411 Silver Spring MD Office (301) Fax (301)

Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11

INFORMATION REGARDING DILATING EYE DROPS

Colorado Cataract & Laser, LLC The Center for Eye Care Excellence

LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA (540) PHONE (540) FAX

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

Agnes Ju Chang, M.D., F.A.A.D.

Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.

Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form

How to Remove a Social History Smoke?

Welcome to Atlanta Southeast Center for Epilepsy & Neurodevelopment, PC

PATIENT REGISTRATION FORM

Marketing Samples Medical Optometry

Referrals It is your responsibility to bring your referral if required. Failure to do so may result in cancellation of your appointment.

Houston Healthcare Therapy Agreement

Patient History Information

Transcription:

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 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 complete then and bring them with you on the date of your appointment. Please also bring with you a list of current medications, your health insurance card(s) and your glasses. If you should need to reschedule your appointment for any reason, please give us at least 24 hours notice. We look forward to serving you. Paul L. Treger, MD Glenn B. Cook, Md, PhD Randall Conrad, OD Tara Brown, MD

PAUL TREGER, M.D. RANDALL CONRAD, O.D. GLENN B. COOK, M.D., PhD. TARA BROWN, M.D. PLEASE REVIEW FOR ACCURACY AND COMPLETE WHERE APPROPRIATE PATIENT INFORMATION Name: Date of Birth: Address One: Social Security #: Address Two: Sex: F City: Usual Provider: GLENN COOK State: Zip: Employer: Home Phone#: Emergency Contact: Work Phone#: Emergency Phone#: Cell Phone#: Emergency Relationship: GUARANTOR INFORMATION Name: Date of Birth: Address One: Social Security#: Address Two: City: Employer: State: Zip Employer Address: Home Phone#: Employer City: Work Phone#: Employer State: Zip: Cell Phone#: INSURANCE INFORMATION Primary Insurance: Secondary Insurance: Certificate#: Certificate#: Group Number: Group Number: Group Name: Group Name: Copay: Copay: Subscriber Name: Subscriber Name: Authorization To Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to myself or to my Provider, La Mesa Eye & Paul Treger when he accepts assignment. Authorization To Release Medical Information. I hereby authorize my Provider, La Mesa Eye & Paul Treger to release any information necessary for my course of treatment. Signed (patient or parent if minor) Date

PAUL L. TREGER, M.D., F.A.C.S GLENN B. COOK, MD, PhD Medical History Form TODAYS DATE: PATIENT NAME FAMILY (PRIMARY) PHYSICIAN PHONE #( ) DO YOU HAVE ANY CURRENT MEDICAL PROBLEMS? PLEASE EXPLAIN CURRENT MEDICATIONS CURRENT EYE MEDICATIONS ALLERGIES YES NO PLEASE LIST MEDICAL SYSTEM REVIEW DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING: ( ) HIGH BLOOD PRESSURE ( ) CANCER OF ANY KIND ( ) DIABETES ( ) KIDNEY DISORDER ( ) BREATHING PROBLEMS ( ) THYROID DISEASE ( ) MIGRAINE HEADACHES ( ) STROKE ( ) HEART PROBLEMS ( ) SKIN DISORDER ( ) ANEMIA ( ) INTESTINAL DISORDER

PRIOR SURGERIES (INCLUDING EYE SURGERY) FAMILY HISTORY: FAMILY MEMBER: ( ) DIABETES ( ) HEART DISEASE ( ) HIGH BLOOD PRESSURE ( ) CANCER ( ) CATARACTS ( ) GLAUCOMA ( ) RETINAL DISEASE ( ) BLINDNESS SOCIAL HISTORY ( ) SMOKER PACKS PER DAY ( ) ALCOHOL USE AMOUNT PER DAY OCCUPATION EYE HISTORY: ( ) CONTACT LENSES IF YES WHAT TYPE? PREVIOUS EYE SURGERY: (PLEASE PROVIDE DATES) CATARACT R L LASER R L WHAT TYPE GLAUCOMA R L OTHER R L WHAT TYPE

EYE SYSTEM REVIEW: DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING PROBLEMS: ( ) COMPLETE OR PARTIAL LOSS OF VISION ( ) CATARACTS ( ) GLAUCOMA ( ) MACULAR DEGENERATION ( ) EYE DISEASE FROM DIABETES ( ) IRITIS OR INFLAMMATION INSIDE THE EYE ( ) DRY EYES ( ) EYELID INFECTIONS (BLEPHARITIS) ( ) LAZY (AMBLYOPIC) EYE ( ) CROSSED OR DEVIATED EYES ( ) DOUBLE VISION ( ) GROWTHS ON EYELIDS OR EYES ( ) EYE INJURY ( ) CONSTANT TEARING OF EYE(S) WHAT IS THE PURPOSE OF TODAY S EXAM?

PAUL L. TREGER, M.D. Tara L. Brown, M.D. GLENN B. COOK, M.D. Randall Conrad, O.D. TO OUR PATIENTS Refraction The portion of an eye exam known as a Refraction is not covered by most insurance companies (including Medicare). This part of the examination is done to determine your current need for glasses. The charge for the Refraction is $35.00. If you do not wish this optional portion of the examination to be performed, please inform the technician at the beginning of the exam. If you wish to have this portion of the exam completed, and it is known that your insurance will not cover it, you will be asked to pay the $35.00 charge upon completion of your examination. No Show/ Canceled Appointment Policy If you fail to give our office 24 hour notice of cancellation of your appointment we reserve the right to charge you $25.00 for your appointment time. Returned Check Fee $25.00 Service charge Collection Services $50.00 Administration Fee will be added to the account Form Fee $10.00 Administration Fee for forms required to be completed by Physician Insurance Patients (PPO or HMO) You agree to assume full financial responsibility for all medical services provided to you in the event it is determined by the insurance carrier that you were ineligible for benefits at the time of service, did not provide correct insurance information, or the service was not covered. Signature Date Print Name

2024 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information