Patient Registration Form Patient Registration Form Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number* Please provide a telephone number, with area code, so we can contact you.Daytime PhoneCell Phone I would like to receive text message confirmations. I would not like to receive text message confirmations. Email Address* I would like to receive email confirmations. I would not like to receive email confirmations. Personal InformationGender Indentification* Female Male Preferred Pronouns She/Her He/His They/Them Date of Birth* MM slash DD slash YYYY Social Security Number (last 4 digits only!) Preferred Language*Select Preferred Language >EnglishSpanishFrenchJapaneseDecline to specifyRace*Decline to specifyAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanicNative Hawaiian or Pacific IslanderWhiteEthnicity*Decline to specifyHispanic or LatinoNative Hawaiian or other Pacific IslanderNot Hispanic or LatinoMarital StatusSelect Marital Status >DivorcedLegally SeparatedMarriedSingleWidowedOtherEmployment Status*Employed Full-TimeEmployed Part-TimeNot EmployedOn Active Military DutyRetiredSelf-EmployedStudent Full-TimeStudent Part-TimeOtherEmployer Occupation How were you referred to our office?*Select Referral Type >Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherCommunication Preference*Select Communication Preference >EmailPostalTelephoneEye HistoryPlease check off any current conditions you suffer from* None Headaches Glare/Light Sensitivity Tired Eyes Amblyopia (lazy eye) Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Discharge From Eyes Drooping eyelid(s) Redness Sandy or Gritty Feeling Strabismus (crossed eye) Lazy Eye Blurred Vision at Distance Blurred Vision at Near Halos Double Vision Floaters or Spots Fluctuating Vision Loss of Side Vision Macular Degeneration Glaucoma Cataracts Do you use lubricating eye drops? Yes No Glasses HistoryDo you wear glasses?* Yes No Do you think you need glasses? Yes No Why? My vision is blurry in the distance. My vision is blurry up close. My vision is blurry in the distance and up close. What glasses do you own?* Single Vision Distance Single Vision Reading Bifocals Safety Glasses Progressive Trifocals Sports Glasses Sunglasses R Other glasses: Please tell us what other kinds of glasses you own. Please check all that apply.* I am satisfied with my glasses. I am not satisfied with my glasses. I wish to improve the distance correction. I wish to improve the near correction. (Progressives) I wish to improve the middle-range. My lenses are heavily scratched. I would rather not wear glasses. I would like to update my frames and lenses. I would like to update my lenses and keep my old frames. How many hours a day do you use a computer or other digital devices?Please enter a number from 0 to 24.How many inches away, approximately, do you sit from your computer monitor?Please enter a number from 0 to 120.Contact Lens HistoryDo you wear contact lenses?* Yes No What brand of contact lenses do you wear? How old are your current lenses? How often do you replace or dispose your contact lenses? What brand of solution do you soak your lenses in? What is your typical wearing schedule? In hours per day:Please enter a number from 0 to 24.What is your typical wearing schedule? In days per week:Please enter a number from 0 to 7.Please check all that apply.* I do not wear contacts. I am interested in trying contacts. I'm not having any issues and am satisfied with my lenses. I am having problems with my current contact lenses There are times when I would rather not be wearing contact lenses I am interested in a non-surgical method of vision correction I am interested in changing or enhancing my eye color I am interested in refractive laser surgery I don't have a spare set of contact lenses My spare contact lenses have an incorrect prescription Medical HistoryWhen, approximately, was your last eye exam?* Where did you get your last eye exam? When, approximately, was your last physical exam?* Who is your primary care physician?* Do you drink alcohol?*NoYes, 1 per weekYes, 1 per dayYes, 2 or 3 per dayYes, 4 or more per dayDo you smoke tobacco?*NoYes, 1/2 a pack per dayYes, 1 pack per dayYes, more than 1 pack per dayPlease list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.). If none, write "none" or "N/A."*Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment). If none, write "none" or "N/A."*Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.). If none, write "none" or "N/A."*Please list all prescription and over-the-counter medications or vitamins you take. If none, write "none" or "N/A."*Please list all drug allergies you have. If none, write "none" or "N/A."*Please list all hospital surgeries you have ever had. If none, write "none" or "N/A."*Please check off any current conditions you suffer from. If none, please select "N/A or NONE".* N/A or NONE Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat) Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet) Respiratory problems (eg. Shortness of breath, wheezing, coughing) Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints) Skin problems (eg. Rashes, excessive dryness, growths or lumps) Neurological problems (eg. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (eg. Depression, anxiety) Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands) Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens) Primary InsuranceDo you have insurance?* Yes No ***** Please bring all insurance cards with you to your appointment. *****Insurance Company Name* Insured's Name* First Last Identification Number* Group Number Insured's Date of Birth* MM slash DD slash YYYY Patient's Relation to Insured* Secondary InsuranceDo you have secondary insurance? Yes No If you have coverage through another plan/organization, please fill in the details below.Insurance Company Name Insured's Name First Last Identification Number Group Number Insured's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured CommentsIf you have any comments you would like to add, please enter them here.Financial ResponsibilityI understand that most insurance policies pay only a portion of the total charges and if I have questions about my coverage I will contact my insurance representative. Brattleboro Family Eye care can not guarantee the accuracy of benefit information given to them by insurance companies. I authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of medical or vision benefits either to the physician or supplier of services rendered or to myself if the provider does not accept assignment. I understand that I am responsible for any balance my insurance does not pay. Payment (including deductibles, co-pays, and non-covered services) is expected at the time services are provided. Any balances that are beyond 60 days past due are subject to an 18% annual interest rate. By signing below, I acknowledge that I have read and agree to the information on this form.I acknowledge that I have read the above information*To sign : Draw your signature in the box using a mouse or finger. Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy PhoneThis field is for validation purposes and should be left unchanged.
