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!
New Patient Registration

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

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.
*

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

Clear
Date

Month Day Year
Should be Empty:

New Patient Registration