Patient Registration Form

Patient Registration and Medical History Form

Please be sure to bring your medical insurance card, any eyewear, contact lenses, and contact solution.
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First Name
Middle Initial
Last Name
How did you hear about us?
Other
Birth Date
SSN
Sex
Employer/Occupation
Physical Address
City
State
Zip Code
Mailing Address
Email Address
Home Phone
Work Phone
Cell Phone
Communication Preference
Marital Status
Spouse Name
Spouse Phone
Spouse Employer
Primary Language
Race
Ethnicity
Medical Doctor
City
Pharmacy
City
If the patient is a child or student, list both parents
Mother
Phone Number
Employer
Father
Phone Number
Employer
If not the patient, who is responsible for the bill?
Relationship
Phone

Insurance Information

*We must have a copy of all insurance cards on the day of service*

Medicare
Medicaid
Medicare Supplement Insurance Name
Policy Number
Health Insurance Name
Policy Number
Policyholder Name
Policyholder Date of Birth
Vision Insurance Name
Policy Number
Policy Holder Name
Policyholder Date of Birth

Privacy Notice, Assignment of Benefits, and Financial Agreement

​​​​​​​The HIPPA Privacy Rule gives individuals a fundamental right to be informed of the privacy practices of health plans and health care providers, how medical information may be disclosed, and how you can get access to this information. The complete HIPPA Privacy Rule is available for you to review upon request.

It is the patient/guardian responsibility to know their insurance coverage. Patients should be aware of their benefits, including which providers are contracted with their plan, covered and non-covered benefits, authorization requirements, and cost share information such as deductibles, co-insurance, and co-pays, and when they are eligible for services. If you are not familiar with your plan coverage, we recommend you contact your carrier directly prior to your services.

I consent to have my prescription to be made digitally available on the patient portal upon payment in full of my examination and contact lens services. I acknowledge that I have received my prescription.

The patient/guardian authorizes payment of all private insurance, medical/surgical benefits, including major medical benefits to go to the Mabee Eye Clinic. A photocopy of this assignment is to be considered as valid as an original. The patient/guardian is financially responsible for all charges regardless of insurance. A parent or guardian must sign if patient is under 18 years old.

Person(s) you allow us to discuss your medical record and/or billing information with: (if any)
Name
Relationship
Phone Number
Date
Name
Relationship
Phone Number
Date
Sign
Date

Social History

Tobacco Products
Alcohol Use

Current Vision Correction

Do you currently wear glasses?
How often do you wear your glasses?
How often do you replace your contacts?

Review of Systems

Allergies
Medications / Supplements
Eye Surgery
Do you currently, or have you ever had any problems in the following areas?

Family Health History

Select all that apply.

Glaucoma
Other Family Members
Cataract
Other Family Members
Macular Degeneration
Other Family Members
Retinal Tears or Detachment
Other Family Members
Blindness AND/OR vision impairment
Other Family Members
Strabismus (eye turn)
Other Family Members
Amblyopia (lazy eye)
Other Family Members
Diabetes
Other Family Members
Cancer
Other Family Members
Heart Disease
Other Family Members
High Blood Pressure
Other Family Members
High Cholesterol
Other Family Members
Kidney Disease
Other Family Members
Stroke
Other Family Members
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