Dr. Angela Howell
EyeCare Registration and History Form

Patient Information

Date: _________________
Patient: ___________________________
Adress: ___________________________
    _______________________________
City: _____________________________
State: ______________ Zip: __________

Sex: M F  Age: ____ DOB: ________

Single Married Widowed
Sparated Divorced

Patient SS#: _______________________
Occupation: _______________________
Employer: ________________________
Employer Address: __________________
     ______________________________
Employer Phone: ___________________
Spouse's Name: ____________________
DOB: ________ SS#: _______________
Occupation: _______________________
Spouse's Employer: __________________

Who may we thank for referring you?
_________________________________

Insurance

Who is responsible for this account? _________________________
Relationship to Patient: ________________
Insurance Co.: ______________________
Group #: __________________________
Is patient covered by additional insurance? Yes No
Subscriber Name: ____________________
DOB: ________ SS#: _______________
Relationship to Patient: _________________
Insurance Co.: _______________________
Group #: ___________________________

Assignment and Release
I, the undersigned, certify that I (or my dependent) have insurance coverage with _______________________ and assigned directly to Dr. _________________ all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the docotr to release all information necessary to secre the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature:
__________________________________
Relationship: _____________ Date: _________


Phone Numbers

Home: ______________ Work: ____________ Ext. ______ Spouse's Work: ____________
Best time and place to reach you: ______________________________________________

In Case of Emergency, Contact
Name: ___________________________________ Relationship: ____________________
Home Phone: ______________________________ Work Phone: ____________________

 

 

 



Eye Health History

Physician's Name:_______________________
Date of last visit: ________________________
Date of last eye exam: _____________________
Name of doctor: ________________________

Do you wear glasses: Yes  No
All the time Occasionally Reading
Driving During TV

Do you wear contacts: Yes  No
Type: _________________ Hours/Day: __________
Discribe any problems you have with your contacts:
________________________________________
________________________________________
 

Place a mark on "Yes" or "No" to indicate if you have had any of the following.
Bloodshot Eyes Yes  No
Blurred Vision- Distance Yes  No
Blurred Vision - Near Yes  No
Burning Eyes Yes  No
Cataracts Yes  No
Color Vision Poor Yes  No
Crossed Eyes Yes  No
Discharge from Eyes Yes  No
Dizzy Spells Yes  No
Double Vision Yes  No
Dry Eyes Yes  No
Eye Infection Yes  No
Eye Injury Yes  No
Eye Strain Yes  No
Fainting Spells, Blackouts Yes  No
Floaters or Spots Yes  No
Gaucoma Yes  No
Headaches Yes  No
Itching Eyes Yes  No
Light Sensitive Yes  No
Loss of Vision Yes  No
Migrain Headaches Yes  No
Night Vision Poor Yes  No
Red Eyes Yes  No
Seeing Halos Yes  No
Seeing Flashes Yes  No
Temporary Loss of Vision Yes  No
Twitching Eyelid Yes  No
Vision Poor Yes  No
Watering Eyes Yes  No
   

Medications
Allergies
List the medications you are currently taking, including eye drops:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Pharmacy Name: _____________________
Phone: ____________________________
List your allergies to medications or other substances:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________

 








Health History

Physician's Name: __________________________________Date of last visit: ______________

Place a mark on "Yes" or "No" to indicate if you have had any of the following. Also place a mark to indicate if a blood relative has had any of the following problems.

 
Yourself
Family Member
AIDS/HIV
Yes  No
Yes  No
Arthritis
Yes  No
Yes  No
Artificial Heart Valve
Yes  No
Yes  No
Asthma
Yes  No
Yes  No
Bleeding
Yes  No
Yes  No
Blindness
Yes  No
Yes  No
Cancer
Yes  No
Yes  No
Cataracts
Yes  No
Yes  No
Chemical Dependency
Yes  No
Yes  No
Diabetes
Yes  No
Yes  No
Drug Sensitivity
Yes  No
Yes  No
Emphysema
Yes  No
Yes  No
Epilepsy
Yes  No
Yes  No
Eye Surgery
Yes  No
Yes  No
Glaucoma
Yes  No
Yes  No
Hay Fever
Yes  No
Yes  No
Heart Condition
Yes  No
Yes  No
 
Yourself
Family Member
AIDS/HIV
Yes  No
Yes  No
Arthritis
Yes  No
Yes  No
Artificial Heart Valve
Yes  No
Yes  No
Asthma
Yes  No
Yes  No
Bleeding
Yes  No
Yes  No
Blindness
Yes  No
Yes  No
Cancer
Yes  No
Yes  No
Cataracts
Yes  No
Yes  No
Chemical Dependency
Yes  No
Yes  No
Diabetes
Yes  No
Yes  No
Drug Sensitivity
Yes  No
Yes  No
Emphysema
Yes  No
Yes  No
Epilepsy
Yes  No
Yes  No
Eye Surgery
Yes  No
Yes  No
Glaucoma
Yes  No
Yes  No
Hay Fever
Yes  No
Yes  No
Heart Condition
Yes  No
Yes  No

Medicare Authorization

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr.________________________ for any services furnished me by that doctor. I authorize any 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. I understand my signature requests that payment be made and authorizes release of medical informaiton necessary to pay the claim. If "other health insurance" is indicated in Item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and noncovered services.