NEW PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM
Patient Name (Last, First, MI)*
Preferred name or nickname (if applicable)
Parent/Guardian (if applicable)
Date of Birth*

MonthDayYear
Date
Age
Sex*

MaleFemaleOther
Are you:

SingleMarriedOther
Address*

Street Address

Street Address Line 2

CityState

Zip
Cell Phone*
Home Phone
Email*
example@example.com
Occupation (Or Student)
Employer (Or School)
How did you hear about us?
VISION INSURANCE
Insurance Provider
Primary Member's ID
Last Four of Primary's SSN
MEDICAL INSURANCE
Insurance Provider
Primary Member's ID
Group Number
Primary Member's Name (If not the same as above)
Primary Member's Birthdate

MonthDayYear
Date
MEDICAL HISTORY
Medical Conditions:
Eye Conditions
Current Medications:
Medication Allergies:
Previous Ocular Surgery / Trauma
Reason For Visit:*
Date of last eye exam? (estimate is fine)
CONTACT LENS HISTORY
Do you wear contact lenses?*

YesNoNo, but I am interested
What type of contact lenses do you wear (if applicable)

SoftHard
Contact Lens Brand (if known):
Are you happy with your current contact lenses? If not, please list concerns:
Hours on the computer per day?
OCULAR HEALTH EVALUATION
We believe checking your eye health is just as important as your vision! The doctor is concerned about retinal problems like Macular Degeneration and Glaucoma, as well as systemic diseases such as Diabetes and High Blood Pressure. These conditions can lead to partial vision loss or blindness, and often can develop without warning and can progress without symptoms. We highly recommend doing the following two options in order to assess your ocular and systemic health.
Please check the following if you’d like to proceed:*

Digital Retinal Photography: In lieu of dilation for a contactless and side effect free evaluation. The screening is a fast, painless, non-invasive, and educational way to evaluate the inside of your eyes to rule out any eye conditions. Additional $30.I'd like to learn more or schedule for another timeDilation.Other
If you choose not to be dilated or to receive the Digital Retinal Photography Screening, you agree not to hold the doctors at Eyes On Norbeck Vision Care for any delay in diagnosis or treatment that may occur.
NOTICE OF PRIVACY PRACTICES
This notice describes how your personal health record information may be used or disclosed and how you may gain access to this information. Examples of uses of your health record information include patient recall, prescription verification or request, and for co-management with another health professional. Signing below indicated that you have been made aware of our privacy practices. We will gladly provide you with a copy of this notice if you would like to keep one for your personal records.
AUTHORIZATION OF INFORMATION
I hereby authorize Eyes On Norbeck Vision Care to apply for benefits on my behalf for covered services rendered by them. I request payment to be made directly to their office. I understand that I am financially responsible for the charges not covered by my insurance company. I certify that the information I have reported with regards to my insurance coverage is correct and further authorize the release of any information, including medical information, for this or any related claim. I permit a copy of this authorization to be used in place of the original. If in the event my account is turned over to a collection agency, I will be responsible for all collection costs, interest, attorneys’ fees and court costs. Please note: The patient is responsible for full payment of services if information is not made available, not current, information is not accurate, benefits are not available, or patient fails to present insurance information. The patient will also be responsible for submitting themselves to agencies for reimbursement if proper information is not provided to office staff.

Thank you for choosing us for your eye care needs. We are delighted to have you as a patient and appreciate the confidence you have placed in us. If you have any questions about this form, please do not hesitate to ask.

All optical prescription orders are custom designed and made. If you find your eyewear unsatisfactory, we will do our best to resolve it. However, all sales are final.
Signature:*

Clear
Date*

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION FORM

VISION INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

CONTACT LENS HISTORY

OCULAR HEALTH EVALUATION

NOTICE OF PRIVACY PRACTICES

AUTHORIZATION OF INFORMATION