Dr Kye Patient Enrollment Form

Save time when visiting our office by filling all of your forms right here on our website! Please feel free to reach to us with any questions. We're here to help!
Patient Registration Form

Please hit "Submit" at the bottom of the page! Please make sure to enter ALL information applicable to you.
Name *

First Name Last Name
Suffix
Date of Birth *

Month Day Year
E-mail *
Sex

Female Male
Marital Status
Last 4 Security Number
Phone Number: *

Area Code Phone Number
Alternate Number
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
In case of emergency...
Emergency Contact:

First Name Last Name
Relationship
Contact Number

Area Code Phone Number
Occupation
Employer/Company
Work Number
Student

Yes No
Grade
School
Spouse

First Name Last Name
Patient?

Yes No
Children(s) names:
Patient?

Yes No
Mother's Name

First Name Last Name
Patient?

Yes No
Father's Name

First Name Last Name
Patient?

Yes No
Referred by

First Name Last Name
Policy holder name:

First Name Last Name
Policy holder DOB

Month Day Year
Policy holder Social Security
Medical Insurance Company
Contract Number
Group Number
Secondary Insurance Company
Contract Number
Group Number
Vision Insurance Company
List ALL current Doctors
Please check today's complaints

Blurred distance vision Blurred computer vision Blurred near vision Burn/Dry Itching Tearing Flashes of Light Floaters None
Medical Family History

Diabetes Cataracts Glaucoma Macular degeneration Turned or Lazy eye Blindness Autoimmune disease
Contacts

New Wear Establish
Previous brand CL
List any Eye drops used
List any eye surgeries
Are you interested in

New Contact Lens Technology LASIK Surgery New Eyeglasses New Sunglasses
List Pharmacy Used
List ALL Current Medications
List any medications allergies
Please list your hobbies
Do you smoke?

Yes No
How much do you smoke?
How long have you smoked?
Do you drink alcohol?

Yes No
How much and how often?
Illegal Drugs

Yes No
Are you pregnant

Yes No
Approximate Height
Approximate Weight
Last Known Blood Pressure
Optomap Notice

The Optomap Retinal Exam provides us with a scan of the retina to confirm the health of your eye and allows our doctors to detect the presence of disease early in its progression. Your Optomap image will be saved in your medical file enabling your doctor to make important comparisons during your annual eye exams. It may not require dilation drops which result in blurred vision and sensitivity to light for several hours. Some patients will need to have their eyes dilated also. The fee for the Optomap Retinal Exam is $39.00 and is not covered by your insurance. Our doctors recommend you have this test done at your annual exam.
Select your Optomap preference *

Yes, I would like an Optomap performed today and I understand that I still, may have to be dilated at the doctor's discretion. Unsure, Please tell me more. No, I decline and understand that using the Optomap greatly enhances my doctor's ability to comprehensively examine your eyes. I understand that early detection of potentially threatening disease is an important part of my thorough eye health evaluation. I am prepared to have my pupils dilated today.
HIPAA Notice

This office is HIPAA compliant and the HIPAA policies and Notice of Privacy Practices are posted in the office and available to read.
Your Acknowledgement *

I acknowledge HIPAA Notice of Privacy Practices
Financial Policy

We have contracts with many insurance companies to accept assignment of benefits for our services. Payment in full will be required unless insurance benefits to cover charges can be verified prior to rendering services. Your co-pay and deductibles will be collected at the time of your visit. We accept Cash, Check. Visa. Mastercard. Discover. American Express, and CareCredit. We will file your insurance claim and you wilt be billed for any amount not covered by the insurance company. Payment is due upon receipt of your statement.
Please Acknowledge *

I have read and understand the "Financial Policy"
Signature *

Clear
Today's Date

Month Day Year
Should be Empty:

Patient Registration Form

Optomap Notice

HIPAA Notice

Financial Policy