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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_______