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Rosin Eyecare Confidential Internal Patient Registration Form
Patient Information
_____New Patient
_____Previous Patient
Patient Name (Last, First) ____________________________________________________ Date _____________
Street ______________________________________________________________________________________
City__________________________________________ State _______________ ZIP _____________________
Home Phone ___________________ Cell phone ____________________ Daytime Phone___________________
Birthdate _____________________________________
Gender:
Male
Female
Email Address _____________________________________ Social Security Number______________________
Occupation ___________________________________ Employment Status: FT
Employer _____________________________________ Marital Status: Single
Referred by:
Insurance Company
Walk In
Employee
Recall
Patient
Coupon/Mailer
Friend
PT
Married
Retired
Self Employed
Divorced
Phone Book
Professional
Widowed
Internet
Referral Persons Name _______________________________________________________________________
Emergency Contact Name______________________________ Phone Number __________________________
Insurance Information
Relationship to Insured Party:
Self
Spouse
Dependent Child
Other ____________________
Person Responsible for Payment (if minor) ________________________________________________________
Vision Insurance _____________________________________________________________________________
Medical Insurance____________________________________________________________________________
Employer Name _____________________________________________________________________________
Primary Card Holder Name ____________________________________________________________________
Birthdate of Primary Card Holder________________________________________________________________
ID or SS#___________________________________________ Group__________________________________
Secondary Insurance Name______________________________________ ID #__________________________
Primary Card Holder Address (if differs from above) _________________________________________________
Rosin Eyecare Financial Responsibility
Thank you for choosing Rosin Eyecare your eyecare needs. We are happy to serve you, and look forward to a long relationship with you, our valued
patient. In an effort to serve you efficiently, we have instituted the following financial policy. The policy below outlines the understanding between
you, the patient, and our office. Our office will, as a courtesy, file your insurance claims based upon the information you provided on your registration
sheet; however, it is your responsibility to provide us with complete and accurate information. You will be asked to provide this information on an
annual basis. Failure to provide information necessary and required by the insurance company will result in the denial of your claim. Insured parties
are expected to know their plan requirements and to abide by any specifications of their insurance plan. Furthermore, if information is requested
from you, by the insurance company, you must provide that information promptly. If your claim is denied, it becomes your responsibility to pay the
balance in full. By signing below, you understand that you will be responsible for the payment of any services not paid by the insurance company
which includes co-payments, deductibles, coinsurance, and non-covered services and denied services not covered by contract by our office and
your insurer. We will assist you in any way possible to be sure the claim is handled properly; we will file your insurance claim for you, and send a
reminder statement when there is a balance to be paid by you. In instances where it is deemed necessary, we reserve the right to refer uncollected
balances to an outside collection agency. By keeping open lines of communication and by providing accurate information, you can be sure your
claims will be handled promptly and efficiently.
Rosin Eyecare requires that all exam fees and copays be paid in full at time of service, and a deposit of 50% when ordering materials.
Thank you in advance for your cooperation.
By signing below, I agree that I am ultimately responsible for payment of services provided to me. My signature below authorizes Comprehensive
Eyecare Physicians to release the information necessary to facilitate the payment of medical claims.
Signature___________________________________________________________________________ Date ______________________________
Revised 8/2012
Patient Name_____________________________________ Date _________________ Birthdate________________
Do you use cigarettes/tobacco?
YES
NO
If yes, how many packs per day? ______________
Do you drink alcohol?
YES
NO
If yes, how many drinks per day? ______________
Do you use other substances?
YES
NO
Do you have any allergies?
YES
NO
If yes, to what _____________________________
Are you allergic to any medications? YES
NO
If yes, to what _____________________________
Please list all medications (including over the counter medicines and vitamins/supplements)
you are taking:_________________________________________________________________________________
_____________________________________________________________________________________________
Are you interested in Laser Vision Correction?
YES
NO
Would you like more information regarding Laser Vision Correction?
YES
NO
Which of the following problems are you noticing? (please circle all that apply)
If there are any changes since your last visit, please update accordingly:
Blurred Distance Vision
Blurred Near Vision
Eyestrain
Double Vision
Headache
Itching
Watering
Redness
Burning
Sandy/Gritty/Dry Feeling
Night Vision Difficulty
Sensitivity to Sunlight or Bright Lights
PAST OCULAR HISTORY:
Have you had: (please circle)
Laser eye surgery:
Surgery for either eye:
Eye injury:
Eye infection:
NO
NO
NO
NO
Explanation
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
REVIEW OF SYSTEMS—Please explain all “yes” answers
Have you had problems with: (please circle)
Fever, weight loss, fatigue
NO
Rashes/other skin problems
NO
Head trauma
NO
Headache
NO
Ears, nose, or throat
NO
Neck pain/surgery
NO
Lungs/breathing
NO
Cardiovascular:
Heart disease
NO
High blood pressure
NO
Stomach/intestines
NO
Liver disease
NO
Kidney, bladder, genital
NO
Bones/arthritis
NO
Neurologic problems/stroke
NO
Lymphatic system
NO
Bleeding disorder
NO
Psychiatric disorder
NO
Diabetes
NO
Thyroid problems
NO
Other
NO
Are you pregnant
NO
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
YES How many years?_________________________________
YES _________________________________________________
YES _________________________________________________
YES _________________________________________________
MEDICATIONS:
Eyedrops:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Prescription Medication:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
ALLERGY HISTORY:
Medication Allergies?
NO
Allergy to iodine or shellfish? NO
Explanation
YES ______________________________________________
YES ______________________________________________
FAMILY HISTORY:
Blindness
Glaucoma
Macular degeneration
Retinal detachment
NO
NO
NO
NO
Relationship to Patient
YES ______________________________________________
YES ______________________________________________
YES ______________________________________________
YES ______________________________________________
SOCIAL HISTORY:
Cigarette smoker? (please circle)
Alcohol? (please circle)
Never
None/rare
Current
<1 drink/day
Former, but stopped
>1 drink/day
Do your hobbies or leisure time activities include: (check all that apply)
Racquet Sports (Tennis, Raquetball, etc.)
Snow Boarding/Skiing
Outdoor Sports (Baseball, Softball, Soccer)
Gardening/Yardwork
Outdoor Activities (Fishing, Golf, Boating)
Home Repair/Power Tools
Water Sports
Archery/Shooting
Hockey
Auto Mechanics
Running/Biking
Swimming/Scuba
Driving/Motercycling
Computers/Reading
Scrapbooking/Crafts/Sewing
Other _______________________________________________________________________
Reviewed:
Date______ Initials_______
Date______ Initials_______
Date______ Initials_______