New Patient Registration Form New Patient Registration Form Select Office*Boca RatonPlantationPalm BeachName* First Last Phone*Email Address* Address* Street Address City ZIP / Postal Code Patient's Date of Birth* MM slash DD slash YYYY Primary Medical Insurance* Vision Insurance* Last 4 SSN* If the policyholder is also the patient, click here Yes No Primary policy holder name Primary policy holder DOB MM slash DD slash YYYY last 4 digits of your SSN Member ID* Today's Date MM slash DD slash YYYY Please present BOTH Medical and Vision information NOW in order to insure that all benefits are applied appropriately to the fees today.Necessary Information DataPlease check all that applyMarital Status: Single Married Divorced Widowed Employment Status: Unemployed Employed Full Time Employed Part Time Student Retired Self-Employed Ethnicity: Asian Black/African-American Hispanic White Decline to respond Please list your employer: Please list your occupation: VERY IMPORTANT! NEW PATIENTS ONLYWho may we thank for referring you to our office? If not referred, how did you choose our office for your needs?Another Doctor Signage/Location Insurance List Newspaper Flyer Yellow pages Web pages(search engine) I have reviewed and understand that the Premier Eye Center Privacy and patient Consent Policy is displayed in office, on our website, and I can ask for a copy (printing/electronic) of it at any time. I (patient or guardian) consent that all information I have submitted is accurate.Signature(Patient or Guardian)Date MM slash DD slash YYYY To have your chart accessible to someone else on your behalf for medical, financial concerns, please put name(s) below:Name First Last Number: If no name is entered and the patient is over 18 years old despite insurance coverage we will need written consent by the patient.MEDICAL HISTORYName of Family Physician: Date of Last Physical Exam: MM slash DD slash YYYY Do you have any allergies to medications? Yes No If yes, please explain: List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): Height: feet inches Weight: lbs. Are you currently pregnant or nursing? Yes No Do you use tobacco products? Yes No If yes: Type Amount How long Do you drink alcohol? Yes No If yes: Type Amount How long Do you use recreational drugs? Yes No If yes: Type Amount How long List major injuries, surgeries, and/or hospitalizations you have had Do you currently, or have you ever had any problems in the following areas?Constitutional Fever, weight loss/gain Yes No Integumentary (skin) Yes No NeurologicalHeadaches/Migraines Yes No Stroke / Seizures Yes No EndocrineThyroid/Other/Glands Yes No Ear, Nose, Mouth, ThroatAllergies/Sinus Yes No Chronic Cough Yes No Dry Throat/Mouth Yes No RespiratoryAsthma Yes No Chronic Bronchitis/Emphysema Yes No Vascular/CardiovascularDiabetes Yes No Heart Pain Yes No High Blood pressure Yes No Vascular Disease Yes No GastrointestinalCrohnŹ¼s Disease Yes No Acid reflux/IBS Yes No GenitourinaryGenitals/Kidney/Bladder Yes No Bones/Joints/MusclesRheumatoid Arthritis Yes No Muscle pain / Joint pain Yes No Lymphatic/Hematologic Anemia / Bleeding Problems Yes No Allergic/Immunologic Yes No Psychiatric Yes No EYE HEALTH HISTORYThe information in this confidential case history form is critical to the evaluation of your vision and health.Date of last eye exam: MM slash DD slash YYYY By Whom: Do you wear glasses? Yes No Have you ever tried contact lenses? Yes No Do you currently wear contact lenses? Yes No What kind? Solution used? If you wear contact lenses, are you satisfied with the vision and comfort? Yes No Do you have a backup pair of glasses? Yes No Have you ever been diagnosed or treated for the following? Cataracts Iritis/Uveitis Corneal Abrasion Lazy Eye Eye Infection Macular Degeneration Eye Injury Retinal Detachment Glaucoma Other Eye Disorders Do you experience or have you ever experienced:MEDICAL CONCERN: Flash of light Headaches Burning Redness Itchiness Watering Tearing Grittiness Glare Soreness Distorted vision Eye turn Crossed eyes Tired eyes Loss of vision Eye pain Occasional dryness Light sensitivity Mucous discharge Loss of side vision Sties or Chalazion Foreign body sensation Floaters/small spots Chronic infection of the eye and/or lid VISION CONCERN: Blurry vision Double vision Night driving Halos Is there anything specific that you want to address today?Such as: Lasik Contact Lenses Blue light lens technology Sports goggles Transitions UV protection Other If other, please specify: FAMILY HISTORYBlindness Yes No Relationship Cataracts Yes No Relationship Corneal Problems Yes No Relationship Crossed eyes/Lazy eyes Yes No Relationship Glaucoma Yes No Relationship Macular Degeneration Yes No Relationship Retinal Detachment Yes No Relationship Arthritis Yes No Relationship Cancer Yes No Relationship Diabetes Yes No Relationship Heart Disease Yes No Relationship High Blood Pressure Yes No Relationship Kidney Disease Yes No Relationship Lupus Yes No Relationship Thyroid Disease Yes No Relationship If you answered YES to any of the above or have a Condition not listed, please explain & list medications:Is the the patient the insurance policyholder? Yes No Primary policy holder name* First Last Primary policy holder DOB* MM slash DD slash YYYY Policy holder last 4 SSN* Test 1: Optomap Retinal ScreenerWe at Premier Eye Center perform a state-of-the-art digital scanning technology as part of yout annual medical eye exam. This allow our doctors to view the inside of your eye without the use of dilation drops, unless dilation is necessary. The OPTOMAP allows the doctor to evaluate your retina for problems such as diabetes, high blood pressure, retinal rips, tumors, bleeding, and several other medical eye conditions. The doctor is also better able to evaluate and monitor any changes by comparing the images from year to year. This scanning system is safe for both kids, adults and during pregnancy. Test 1: The $49 copay is incorporated into today's copays (standard care). It is strongly recommended that ALL patients have a thorough examination of their retina every year. Without the Optomap or a dilated examination, serious eye conditions can be missed. Dilation may still be required.Test 2: Glaucoma and Visual Field Testing(optional)We utilize the newest technology for glaucoma screeing the Humphrey FDT Matrix. This will detect any changes related to glaucoma or pathology existing behind the eye. The technology also give information regarding the visual pathway from the brain to the eyes. This helps in the management of headaches and/or migraines, and rules out potential consequences such as tumors or brain masses. If treatment is necessary, our doctors are able to treat and manage eyes disease-related to abnormal visual fields. I elect to have the FDT Matrix screener Original Price $100.00 Now $39.00 I decline addintional FDT Matrix screening SignatureBy signing I acknowledge any feeās associated to my examinationDate MM slash DD slash YYYY
