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VisionMakers
100 Merchant Lane, Suite 101
Pittsburgh, PA 15205

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412-385-4664

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Located in the Carpenter’s building at Ridge Road in Pittsburgh

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Hours & Location
About Us
Eye Care Services
Our Optician’s Picks
Eyeglasses
Contact Lenses
- Order Glasses and Contact Lenses
Patient Resources
Insurance

Hours & Location
About Us
Eye Care Services
Our Optician’s Picks
Eyeglasses
Contact Lenses
- Order Glasses and Contact Lenses
Patient Resources
Insurance

Home » Patient Resources » Patient Registration Form

Patient Registration Form

1Patient Registration

2Medical History

Patient
Name*
First Middle Initial Last
Nickname
Gender
- Male
- Female
Student
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Social Security Number
Age
Date of Birth*
MM slash DD slash YYYY
What is the best way to reach you by phone?*
- Home phone
- Cell phone
Home Phone*
Cell Phone*
Work Phone
E-mail Address*
I am interested in being registered for online contact lens orders:
- Yes (e-mail required above)
- No
I am interested in receiving e-mail promotions for savings on glasses and/or contacts
- Yes
- No
Marital Status
- Single
- Married
- Divorced
- Widowed
Employment
- Full-Time
- Part-Time
- Retired
- Unemployed
Name of Employer/Occupation
Address of Employer
Is patient covered by another group vision plan?
- Yes
- No
If "yes", complete the following:
Vision Plan Name
Union Local
Group #
Name and Address of Carrier
Was an accident involved?
- Yes
- No
If "yes", was the injured person at work when the accident happened?
- Yes
- No
Has cataract surgery been performed?
- Yes
- No
If yes:
Left Eye - Date of Surgery
MM slash DD slash YYYY
Doctor
Right Eye - Date of Surgery
MM slash DD slash YYYY
Doctor
Falsification or misrepresentation of information requested below may result in action(s) deemed appropriate by Employer and/or insurance. (Please answer all questions before claim is completed.)
Patient's Relationship to Insurance Enrollee*
- Self
- Spouse
- Dependent/Child
Name of Insured
Name
First Middle Initial Last
Social Security Number
Address
Street Address Address Line 2 City State ZIP Code
Age
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Name of Employer
Address of Employer
Authorization
I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for services to the physician OR organization furnishing the services and authorize such physician OR organization to submit a claim to my insurance carrier OR Medicare for payment. I authorize any holder of medical or other information about me to release to insurance carriers OR the Health Care Financing Administration and its agents OR the Social Security Administration or its intermediaries OR any agency, group or person(s) necessary to secure payment any information needed for this or related Medicare claim. *For and in consideration of services rendered and to be rendered by the above listed medical provider, I hereby guarantee payment of all charges incurred for this account. *The patient or his/her representative recognizing the need for health care, consents to the above listed medical provider rendering services as ordered by the physicians, including medical or surgical treatment, laboratory procedures, X-ray examinations or other services rendered under the general and specific instructions of the physicians. *I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct.
Date
MM slash DD slash YYYY
Signature of Patient (Parent/Guardian if minor)

Past Medical History and Review of Symptoms
(please give details for "yes" answers)
Diabetes?*
- Yes
- No
Family history of Diabetes?*
- Yes
- No
Heart Disease or Stroke (specify below)?*
- Yes
- No
Family history of Heart Disease or Stroke?*
- Yes
- No
High Cholesterol?*
- Yes
- No
Currently pregnant or nursing*
- Yes
- No
Autoimmune disease (Lupus, Sarcoid, Wegener's, Fibromyalgia, Rheumatoid)*
- Yes
- No
Infectious Disease (HIV, Hepatitis, TB)*
- Yes
- No
Depression/Anxiety Disorders*
- Yes
- No
Skin Disorders (specify below)*
- Yes
- No
Arthritis (specify below)*
- Yes
- No
High Blood Pressure*
- Yes
- No
Asthma or Lung Disease*
- Yes
- No
Thyroid Problems*
- Yes
- No
Stomach or GI Problems*
- Yes
- No
Cancer (specify below)*
- Yes
- No
Bone or Muscle Problems*
- Yes
- No
List surgeries and specify from above:
Medicine Allergies?*
- Yes
- No
Please list medicine allergies:
Medications?*
- Yes
- No
Please list medications:
Medication Name Dose (mg) Times Daily
Family Doctor
Phone
Past Eye History and Surgery
(please give details for "yes" answers)
Glaucoma?*
- Yes
- No
Family history of Glaucoma?*
- Yes
- No
Macular Degeneration?*
- Yes
- No
Family history of Macular Degeneration?*
- Yes
- No
Eye Surgery/Lasers (specify below)*
- Yes
- No
Retinal Detachments*
- Yes
- No
Lazy Eye or Muscle Surgery*
- Yes
- No
Eye Inflammation (iritis, episcleritis)*
- Yes
- No
List eye surgeries and specify others:
Eye Drops:
% Eye (R/L) Times Daily
What type of contacts do you wear?*
- Soft
- Hard
- Don't wear them
Do you have them in now?*
- Yes
- No
How many days ago did you last have them in?
Have you had past contact lens problems?*
- No
- Yes
- Yes, and quit wearing them
Social History
Smoke now?
- Never
- Rarely
- Daily
In the past?
- Never
- Rarely
- Daily
Alcohol intake?
- Never
- Rarely
- Daily

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Preferred Date & Times*
Patient Type*
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Name*
First Last
Phone*
Email*
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Comments
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VisionMakers Pittsburgh

100 Merchant Lane, Suite 101
Pittsburgh, PA 15205

Phone: 412-788-4664
Toll Free: 800-788-8701
Email: paoffice@visionmakers.com
(Do not send personal health information by email.)

Monday: 8:00 AM - 6:00 PM
Tuesday: 8:00 AM - 6:00 PM
Wednesday: 8:00 AM - 6:00 PM
Thursday: 8:00 AM - 6:00 PM
Friday: Closed
Saturday: Closed
Sunday: Closed

Hours & Location
About Us
Eye Care Services
Our Optician’s Picks
Eyeglasses
Contact Lenses
Patient Resources
Insurance

Hours & Location
About Us
Eye Care Services
Our Optician’s Picks
Eyeglasses
Contact Lenses
Patient Resources
Insurance

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Privacy Policy

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Contact Us
What’s New
Disclaimer
Privacy Policy

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VisionMakers Pittsburgh - Located at 100 Merchant Lane, Suite 101, Pittsburgh, Pennsylvania 15205 Phone: 412-788-4664 https://www.visionmakerspittsburgh.com

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