Patient Registration Forms LOCATION:(Required) Americus, GA Leesburg, GA Montezuma, GA Please select the location where you have the appointment.Patient IDChart#Name First Middle Last DOB MM slash DD slash YYYY Gender,(Optional) Race. Ethnicity. SSN.Marital Status: Single Married Divorced Employer. Occupation Home Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number: CellHome.WorkEmail Primary Insurance:Insurance Company Name. Phone #. Insured’s Name. Insured’s DOB MM slash DD slash YYYY Patients relation to insured ID Number.Group Number.Address Street Address City State / Province / Region ZIP / Postal Code Secondary Insurance: Yes No SSN of insured:Eye Signs and Symptoms:Please check any that apply. Itching Tired eyes Floaters or Spots Glare/Light Sensitivity Burning Headaches Infection of eye or lid Loss of Vision/ side Vision Dryness Double Vision Mucous discharge Sandy or Gritty feeling Redness Watering eyes Eye pain/Soreness Blurred vision at Distance/Near Haloes Drooping eyelids Fluctuating Vision Foreign Body sensation Glasses/Contact History:Do you wear Glasses? Yes No Do you wear Contacts? Yes No When was your last eye exam? MM slash DD slash YYYY Where was your last eye exam? Eye History:Have you been diagnosed with any of the following eye conditions? Please Check any that apply. Dry eye Diabetic Retinopathy Retinal Detachment Glaucoma Amblyopia (Lazy eye) Strabismus (Crossed eye) Stye Cataracts/Cataract Surgery Blepharitis Allergies Corneal Disease Age Related Macular Degeneration History of Eye Injury:Please check any that apply. Abrasion Chemical Burn Foreign Body Welding Burn Blunt Trauma Who is your primary care physician?. When was your last physical exam?. MM slash DD slash YYYY Do you smoke? Yes No Do you drink alcohol? Yes No Medical History:Have you been diagnosed with any of the following medical problems. Hypertension Diabetes Thyroid Heart Attack Heart Disease Stroke Cancer Seizures Emphysema Cholesterol Depression HIV Sickle Cell Dementia Asthma Migraine Headaches ADHD Autism TIA Gout If you have any diagnoses not listed above please list them here: Add RemovePlease list all hospital surgeries you have had: Add RemovePlease list all prescription and over the counter medications you are taking: Add RemovePlease list any drug allergies you may have: Add RemovePlease list any Medical or Eye conditions that run in your family (blood relatives) Diabetes, Hypertension, Cancer, Glaucoma, Macular Degeneration, etc.. Add RemoveUntitled Chest pain Heart Racing Ringing in your ears Ulcers in your mouth Frequent thirst Stomach aches Bruise easily Skin Rashes Joint pain Joint swelling Numbness in arms or legs Weakness Dizziness Hallucinations Shortness of breath Coughing INSURANCE AUTHORIZATIONI REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS OR OTHER INSURANCE BE MADE EITHER TO ME OR ON MY BEHALF TO REGIONAL EYE CENTER FOR ANY SERVICES FURNISHED ME. I AUTHORIZE HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.Signature of BeneficiaryDate MM slash DD slash YYYY To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform Regional Eye Center of any changes in medical status. I also understand that I am responsible for all charges incurred.SIGNATURE OF PATIENT, PARENT or GUARDIANDate MM slash DD slash YYYY
