Returning Patient Registration Form Select Office*Boca RatonPlantationPalm BeachChart #:Today's Date* Date Format: MM slash DD slash YYYY Name* First Last Phone*Email Address* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient's Date of Birth* Date Format: 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 namePrimary policy holder DOB Date Format: MM slash DD slash YYYY last 4 digits of your SSNMember IDPlease 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:SingleMarriedDivorcedWidowedEmployment Status:UnemployedEmployed Full TimeEmployed Part TimeStudentRetiredSelf-EmployedPlease list your employer:Please list your occupation:MEDICAL HISTORYName of Family Physician:Date of Last Physical Exam: Date Format: MM slash DD slash YYYY Any NEW allergies to your medication list?YesNoIf yes, please explain:List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): Height: feet inches Weight: lbs. EYE HEALTH HISTORYThe information in this confidential case history form is critical to the evaluation of your vision and health.Do you have a backup pair of glasses?YesNoHave you ever been diagnosed or treated for the following in the past year(s) since your last visit with us? 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 If there are no changes to your medical history, please check below. No changes Is the patient also the insurance policyholder? Yes No Primary policy holder name*Primary policy holder DOB* Date Format: MM slash DD slash YYYY Policy holder last 4 SSN*To have your chart accessible to someone else on your behave for medical, financial concerns, please put name(s) below:Name First Last NumberTest 1: Optomap Retinal ScreenerWe at Premier Eye Center perform a state-of-the-art digital scanning technology as part of your annual medical eye exam. As a previous patient, we did this same test last year. This allows our doctors to view the inside of your eye without the use of dilation drops unless dilation is necessary. Doing it every year allows for us to monitor any changes that may otherwise not be documented or noticed, which is why it is Premier Eye Centers standard of care and will be done today.Tests 1: The $49 copay is part of today's copays(standard care)Test 2: Glaucoma and Visual Field Testing(optional)As in test 1 we utilize the newest technology for health screening. The Humphrey FDT Matrix will allow the detection of any changes related to glaucoma or pathology existing behind the eye. This also helps in the management of headaches and/or migraines, and rules out tumors. Test 2 only: Glaucoma Screening Testing(optional)I accept Test 2 $39.00I decline Test 2 and no additional feePatient Signature*By signing I acknowledge any fee's associated to my examination. I (patient or guardian) consent that all information I have submitted is accurate.Date Date Format: MM slash DD slash YYYY Print this form
