PATIENT REGISTRATION FORM
This form is transmitted via a secure, hipaa compliant link
Patient Information

Last Name Cellspacer  First Name CellspacerMI Cellspacer Preferred Name
Date of Birth Cellspacer Cellspacer Cellspacer Sex:Cellspacer M Cellspacer F CellspacerEmail
Address Cellspacer City Cellspacer Cellspacer Zip
Home Phone CellspacerCell Phone CellspacerWork Phone
Last exam
Employer/school CellspacerOccupation
Marital Status: Cellspacer MinorCellspacer MarriedCellspacer SingleCellspacer DivorcedCellspacer WidowedCellspacerOther
Current Medications: Cellspacer None
Allergies to medications Cellspacer None
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Routine Vision Coverage
(We accept VSP, Cigna Vision, Metlife Vision, Guardian Vision)
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Insurance Company Name CellspacerSubscriber ID#
Subscriber Name CellspacerRelationship to patient
Subscriber DOB (if different from above)
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Medical Insurance Information
(We accept Cigna and Medicare)
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Insurance Company Name CellspacerSubscriber ID#
Subscriber Name CellspacerRelationship to patient
Subscriber DOB (if different from above)
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  WHAT ARE THE MAIN REASONS FOR YOUR APPOINTMENT?   (Please check all that apply)
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Routine eye exam Double vision Light sensitivity
Need new glasses Seeing flashes/floaters Frequent eyestrain
Need new contacts Eye itching/allergies Frequent headaches
First time contact lens fitting Red eyes Eye pain/soreness
Distance blurred vision Dry/burning eyes Interest in LASIK/PRK
Near blurred vision Tearing/watering eyes  
 Other
I understand that contact lens professional fees are separate from the routine eye exam.
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  CHECK ANY MEDICAL CONDITIONS THAT APPLY TO YOU, or check None: None    
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Diabetes Pregnant/Nursing Migraines/Headaches Autoimmune
High blood pressure Vascular disease/Stroke Cancer Eczema/Skin rash
High cholesterol Seizures Thyroid disease Depression/Anxiety
Heart disease Lung disease/Asthma Arthritis Seasonal allergies
 Other
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  CHECK ANY EYE CONDITIONS THAT APPLY TO YOU, or check None: None    
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Glaucoma Macular degeneration Turned/Lazy eye Eye injury/Surgery
Cataracts Retinal detachment Dry eye/Allergies
Other
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  CHECK ANY EYE CONDITIONS PRESENT IN FAMILY MEMBERS (please state relationship or check none) None    
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Glaucoma Macular degeneration
Turned/Lazy eye Eye injury/Surgery
Cataracts Retinal detachment
Dry eye/Allergies    
Other
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  EYEWEAR QUESTIONNAIRE
Yes No Cellspacer DistanceCellspacer ReadingCellspacer ComputerCellspacer Progressive
Do you wear contact lenses Yes No Cellspacer
CellspacerIf yes:
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CellspacerCellspacer Daily Cellspacer A few times a week Cellspacer A few times a month Cellspacer Other
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CellspacerCellspacer Daily Cellspacer Weekly Cellspacer Monthly Cellspacer Other
Do you have problems with your current glasses/contacts? Yes    No   
Do your eyes tire quickly while reading? Yes    No   
Do you remove your glasses to read up close? Yes    No   
Do you have trouble with night driving? Yes    No   
Do you have trouble with glare? Yes    No   
Do you use a computer, tablet or smartphone regularly? Yes    No   
Are your eyes sensitive to sunlight/bright light? Yes    No   
Do you participate in activities that put your eyes in danger? Yes    No   
Do you wear eyewear for sports? Yes    No   
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  AUTHORIZATION
I hereby authorize Squint Optometry to apply for benefits on my behalf for covered services rendered by them. I request payment to be made directly to their office. I understand that I am financially responsible for the charges not covered by my insurance company, including based on my failure to obtain a referral or meet a deductible. I certify that the information I have reported is correct and further authorize the release of any information, including medical information, for this or any related claim. This authorization may be revoked by me at any time in writing.

I also acknowledge that I have been provided access to SQUINT OPTOMETRY's Privacy Notice and the opportunity to read and ask questions about it. [Click here for the Hipaa Privacy Notice]


Signature of Patient, Parent or Guardian:    / /    
Date: Saturday, November 18, 2017

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