Patient Registration Form 1 Patient Registration2 Medical History PatientName* First Middle Initial Last NicknameGenderMaleFemaleStudentYesNoAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security NumberAgeDate of Birth* Date Format: MM slash DD slash YYYY What is the best way to reach you by phone?*Home phoneCell phoneHome Phone*Cell Phone*Work PhoneE-mail Address* I am interested in being registered for online contact lens orders:Yes (e-mail required above)NoI am interested in receiving e-mail promotions for savings on glasses and/or contactsYesNoMarital StatusSingleMarriedDivorcedWidowedEmploymentFull-TimePart-TimeRetiredUnemployedName of Employer/OccupationAddress of EmployerIs patient covered by another group vision plan?YesNoIf "yes", complete the following:Vision Plan NameUnion LocalGroup #Name and Address of CarrierWas an accident involved?YesNoIf "yes", was the injured person at work when the accident happened?YesNoHas cataract surgery been performed?YesNo If yes:Left Eye - Date of Surgery Date Format: MM slash DD slash YYYY DoctorRight Eye - Date of Surgery Date Format: MM slash DD slash YYYY DoctorFalsification 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*SelfSpouseDependent/ChildName of InsuredName First Middle Initial Last Social Security NumberAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AgeDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleName of EmployerAddress of EmployerAuthorizationI 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 Date Format: 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?*YesNoFamily history of Diabetes?*YesNoHeart Disease or Stroke (specify below)?*YesNoFamily history of Heart Disease or Stroke?*YesNoHigh Cholesterol?*YesNoCurrently pregnant or nursing*YesNoAutoimmune disease (Lupus, Sarcoid, Wegener's, Fibromyalgia, Rheumatoid)*YesNoInfectious Disease (HIV, Hepatitis, TB)*YesNoDepression/Anxiety Disorders*YesNoSkin Disorders (specify below)*YesNoArthritis (specify below)*YesNoHigh Blood Pressure*YesNoAsthma or Lung Disease*YesNoThyroid Problems*YesNoStomach or GI Problems*YesNoCancer (specify below)*YesNoBone or Muscle Problems*YesNoList surgeries and specify from above: Medicine Allergies?*YesNoPlease list medicine allergies: Medications?*YesNoPlease list medications:Medication NameDose (mg)Times Daily Family DoctorPhonePast Eye History and Surgery(please give details for "yes" answers)Glaucoma?*YesNoFamily history of Glaucoma?*YesNoMacular Degeneration?*YesNoFamily history of Macular Degeneration?*YesNoEye Surgery/Lasers (specify below)*YesNoRetinal Detachments*YesNoLazy Eye or Muscle Surgery*YesNoEye Inflammation (iritis, episcleritis)*YesNoList eye surgeries and specify others: Eye Drops:%Eye (R/L)Times Daily What type of contacts do you wear?*SoftHardDon't wear themDo you have them in now?*YesNoHow many days ago did you last have them in?Have you had past contact lens problems?*NoYesYes, and quit wearing themSocial HistorySmoke now?NeverRarelyDailyIn the past?NeverRarelyDailyAlcohol intake?NeverRarelyDaily