Patient Registration Form 1Patient Registration2Medical History PatientName* First Middle Initial Last Nickname Gender Male Female Student Yes No Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 PhoneE-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 CarrierWas 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 InsuredName First Middle Initial Last Social Security Number Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Age Date of Birth MM slash DD slash YYYY Gender Male Female Name of Employer Address of Employer AuthorizationI 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 NameDose (mg)Times Daily Family Doctor PhonePast 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 HistorySmoke now? Never Rarely Daily In the past? Never Rarely Daily Alcohol intake? Never Rarely Daily