PATIENT REGISTRATION FORM
* Required
Patient Information

* Last Name Cellspacer*  First Name CellspacerMI Cellspacer Preferred Name
Date of Birth * CellspacerCellspacer CellspacerAge Cellspacer Sex:Cellspacer M Cellspacer F CellspacerEmail
* Address Cellspacer* City Cellspacer* Cellspacer* Zip
* Either a home or cell number is required  Home Phone CellspacerCell Phone CellspacerHobbies
Primary Care Physician/Practice Name CellspacerLast exam (month)
Employer/school CellspacerOccupation
Emergency contact/relationship CellspacerPhone
Are you a: Cellspacer MinorCellspacer MarriedCellspacer SingleCellspacer DivorceCellspacer WidowedCellspacerOther
* Medications currently taking Cellspacer None
*Allergies to medications Cellspacer None
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Routine Vision Insurance Information
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Insurance Company Name CellspacerSubscriber ID#
Subscriber Name CellspacerRelationship to patient
Subscriber DOB (if different from above) CellspacerEmployer (if different from above)
Street (if different from above) CellspacerCity CellspacerState CellspacerZip
Work Phone # Cellspacer
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Medical Insurance Information
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Insurance Company Name CellspacerSubscriber ID#
Subscriber Name CellspacerRelationship to patient
Subscriber DOB (if different from above) CellspacerEmployer (if different from above)
Street (if different from above) CellspacerCity CellspacerState CellspacerZip
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WHO MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?       Friend/Relative  
Insurance listing Flyer  
Saw sign/building Web page: Ours or Other Referred from Doctor's Office
Newspaper Yelp/Google recommendation
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WHAT ARE THE MAIN REASONS FOR YOUR APPOINTMENT?   (Please check all that apply)
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Distance blurred vision Eye itching/allergies Frequent eyestrain Foreign matter in eyes
Near blurred vision Other Red eyes Frequent headaches Eyelids matted shut
Sudden loss of vision Dry/burning eyes Eye pain/soreness Discharge from eyes
Seeing flashes/floaters Tearing/watering eyes Double vision Interest in LASIK/PRK
Contact lens discomfort Unusual light sensitivity One eye turning in/out Other
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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 Weight Loss/Gain
High Blood Pressure Vascular Disease/Stroke Cancer Eczema/Skin Rash
High Cholesterol Seizures Thyroid Disease Psychiatric
Heart Disease Lung Disease/Asthma Arthritis Autoimmune
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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 THAT ARE PRESENT IN OTHER FAMILY MEMBERS
(please state relationship)
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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LIFESTYLE QUESTIONNAIRE (PLEASE CHECK Yes or No)(Please check all that apply)
Are you planning on purchasing glasses at your visit? Yes    No    Only if there is a change   
Do you have problems with your current glasses/contacts? Yes    No   
Do you your eyes tire quickly while reading? Yes    No   
Do you spend time/work outdoors? Yes    No   
Do you have trouble with night driving? Yes    No   
   
Do you use a computer? Yes    No    How many hours?
Are your eyes sensitive to sunlight/bright light? Yes    No   
Do you have prescription sunglasses? Yes    No   
Are you interested in Laser Vision Correction? Yes    No   
   
Are you interested in nonsurgical vision correction? Yes    No   
Do you have more than 1 pair of current prescription glasses? Yes    No   
Do you have family members in need of eyecare? Yes    No   
Do you participate in any activities that may put your eyes in danger? Yes    No   
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AUTHORIZATION OF INFORMATION
I hereby authorize Shady Grove Eye and Vision Care 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. I certify that the information I have reported with regards to my insurance coverage is correct and further authorize the release of any information, including medical information, for this or any related claim. I permit a copy of this authorization to be used in place of the original. This authorization may be removed by me at any time in writing. If in the event my account is turned over to a collection agency. I will be responsible for all collection costs, interest, attorneys'fees and court costs.

Please note: the patient is responsible for full payment of services if information is not made available, is not current, information is not accurate, benefits are not available or patient fails to present insurance information. The patient will also be responsible for submitting themselves to agencies for reimbursement if proper information is not provided to office staff.
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* Patient/Guardian signature

* Date
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CONTACT LENS EVALUATION FEE
According to the FDA, all contact lenses are considered a MEDICAL DEVICE, since they are inserted directly on your eyes. Therefore, every year, if you want to purchase contacts or get a prescription for them, even if your prescription does not change, you must get a new evaluation for eye health purposes. This fee is separate from your regular exam fee that includes your eyeglass prescription and is inclusive of all contact lens related follow up visits within six (6) months. Depending on the complexity of your prescription, the type of contact lens therapy, and your insurance coverage if applicable, this non-refundable fee can range from $86 and up.
* Please check the box and sign below if you need your annual contact lens evaluation/prescription and agree to this fee: Yes   Cellspacer No


* Patient/Guardian signature
 
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