New Patient Registration | Northwest Family Eyecare

Date*
MM slash DD slash YYYY
Patient Information
Name*
First Last
Date of Birth*
Month
Day
Year
Age*
Parent, Guardian, or Representative
Relationship to Patient
Patient S.S.N.
Home Phone
Cell Phone
Work Phone
Preferred Method of Contact*
May we leave messages regarding your medical information with us on your voicemail*
- Yes
- No
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Marital Status
Email (This is the primary way we contact you.)*
Employer or school
Occupation
Hours on the computer?
How did you find out about our office?
- Zoc Doc
- Internet
- Insurance Locator
- Patient Reference
Patient Reference Name
My visit today is for:*
- Glasses
- Contact Lenses
- Laser Vision Correction
- Office Visit
Date of Last Eye Exam
Month
Day
Year
Doctor
Date of Last Physical Exam
Month
Day
Year
Doctor
Social History
NOTE: This information is kept strictly confidential. However, you may discuss it directly with the doctor if you prefer.
Do you drive?*
- Yes
- No
If YES, do you have visual difficulty when driving?*
- Yes
- No
Do you us tobacco products?*
- Yes
- No
If YES, type/amount/for how long?*
Do you drink alcohol?*
- Yes
- No
If YES, type/amount/for how long?
Do you use illegal drugs?*
- Yes
- No
If YES, type/amount/for how long?
Have you ever been exposed to or infected with any sexually transmitted disease?*
- Yes
- No
If yes, please give details*
Medical History
Are you taking any medications(including eye drops and over-the-counter)?*
- Yes
- No
If yes, please list*
Medication For what?
Are you allergic to any medications?*
- Yes
- No
If yes, please list*
Patient Medical History
Family Medical History
Eye History
Family Eye History
- Glaucoma
- Degeneration
- Cataracts
- Kertoconus
- Strabismus
- Amblyopia
- Other
IF other, please list*
Eye Injuries (foreign objects, black eye, etc)*
- Yes
- No
Eye Disease (Cataract, glaucoma, macular degeneration, etc)*
- Yes
- No
Eye Surgery (cataract, LASIK/PRK, etc)*
- Yes
- No
If yes to any of the above, please explain
Do you wear glasses?*
- Yes
- No
If yes, for how long?*
Do you wear contact lenses?*
- Yes
- No
If yes, for how long?*
Review of Systems
General*
- Pregnant
- Good
- Fair
- bad
Eyes (Ocular Symptoms)*
- Eye pain or soreness
- Fatigue or Tired Eyes
- Dry or Gritty Feeling
- Redness
- Burning
- Itching
- Excess watering
- Mucous discharge
- Chronic infetions
- Squinting
- Glare or light sensitivity
- Haloes around lights
- Double vision
- Loss of vision
- Blurred vision
- Flashes
- Floaters
- None
Constititional*
- Fever
- Weight loss or weight gain
- None
Skin*
- Rosacea
- Metal Allergies
- None
Ear, Nose, Throat*
- Allergies or hay fever
- Sinus infections
- Hearing loss
- Dry Mouth
- None
Respiratory*
- Asthma
- Chronic Bronchitis
- Emphysema
- None
Vascular/Cardiovascular*
- Heart Disease
- High Blood Pressure
- High Cholesterol
- Stroke
- Bypass surgery
- None
Gastrointestinal*
- Acid Reflux
- Intestinal problems
- Liver or Spleen problems
- None
Endocrine*
- Diabetes
- Thyroid or other glands
- Post Menopause
- None
Genitourinary*
- Genitals
- Kidney
- Urinary
- None
Lymphatic/Hematologic*
- Anemia
- Bleeding
- None
Bones/Joints/Muscles*
- Rheumatoid arthritis
- Muscle or Joint pain
- None
Neurological*
- Headaches
- Seizures
- Alzheimer's
- Parkinson's
- Migraines
- None
Psychiatric*
- Anxiety
- Depression
- Insomnia
- None
Immune System*
- Immunocompromised
- None
Dilation Of The Pupils
Dr. Rosa C. Suarez-‐Reyna and Associates strongly recommend that all patients’ pupils be dilated as part of a comprehensive eye examination. Routine dilation of the eyes is recommended at least every 2 years. If you have a condition such as diabetes, high blood pressure, cataracts, headaches, high myopia (nearsightedness), symptoms of flashes of lights or floaters, glaucoma or a family history of glaucoma, you are strongly urged to have your pupils dilated yearly. Dilation involves placing drops in your eyes to enlarge the pupil size. When an eye is dilated, we are able to get a much broader and fuller view of the inside of the eye. This aids the doctor in determining if diseases (such as macular degeneration, glaucoma, and tumors) are present, if there is damage to the retina (such as holes or tears) and in the evaluation of cataracts.

With pupillary dilation, you may experience the following effects:
- Increased sensitivity to light
- A slight blurring of your distance vision
- Inability to focus up close
Every patient is different and therefore these effects my last 2-6 hours
Please check one of the following options below*
- I do consent to having my eyes dilated
- I do understand the importance of the dilation, yet I do not wish to have it performed at this time. I release Dr Rosa C. Suarez-Reyna & Associates, PLLC from any liabilities related to failure to diagnose or treat any eye condition due to the lack of diagnostic information which could have been obtained by the test.
Date*
MM slash DD slash YYYY
Signature*
Payment Policy
This information is provided so that our clients are fully informed of our policies. Please read and sign below

Fees: Our fees reflect the level of care that you receive and the training of the doctors. Estimated amounts of services may be given, but the final amount may be different depending upon the employer plan and other circumstances

Insurance: Your policy is a contract between you and your insurance company. As a courtesy, we bill your insurance carrier, but you are ultimately responsible for the entire bill. If your insurance company does not pay the practice within 90 days, we will expect payment from you. If we later receive a check from your insurer, we will refund your overpayments. Unpaid balances accrue interest at the rate of 1.5% monthly (18% APR) and are send to a Collection Agency after 120 days. If you insurance plan determines a service is not covered, you will be responsible for the full charge. Co-pays, deductibles, and co-insurance are required on the day of service. If the co-pay is not paid at the time of service, a $10 billing fee will be charged. Uncollected fees, either from the insurance, insufficient funds check, stop payment, credit card chargebacks, etc. remain the responsibility of the patient (parent or legal guardian, if a minor). When insurance benefits are verified, the information provided by the customer service representative is NOT A GUARANTEE OF PAYMENT

Materials: Contact lenses require half-down prior to ordering. Glasses require full payment prior to dispensing

Assignment of Benefits: (Applicable if we are filing with Vision or Medical Insurance for you.) At each visit, patients are questioned about any changes in their insurance coverage and insurance card is copied. This is crucial so that your visit is billed correctly. We require all patients to sign a copy of the patient registration form that assigns insurance benefits to be directly to Northwest Family Eye Care, PLLC. If your insurance company sends a payment directly to you, it is your responsibility to make payment to Northwest Family Eye Care, PLLC.

"I hereby authorize my insurance/medical benefits to be paid directly to Northwest Family Eye Care, PLLC. I further authorize release of any medical records or information necessary to process this claim." This assignment of benefits may be revoked by the patient at any time, with prior written notice.
Date*
MM slash DD slash YYYY
Signature*
Acknowledgement of Notice of Privacy Practices
The law requires that Rosa C. Suarez-Reyna & Associates, DBA Northwest Family Eye Care, PLLC make every effort to inform you of your rights related to your personal health information. By signing below, I acknowledge that: (Please check the appropriate statement)*
- I have read or had explained to me Northwest Family Eye Care’s Notice of Privacy Practice and agree to continue my care with Northwest Family Eye Care, PLLC under said terms.
- I was given the opportunity to read Northwest Family Eye Care’s Notice of Privacy Practices and declined, but wish to continue my care with Northwest Family Eye Care, PLLC under the terms of Northwest Family Eye Care’s privacy policies.
- I have read or had explained to me Northwest Family Eye Care’s Notice of Privacy Practice and do not wish to continue my care with Northwest Family Eye Care, PLLC under said terms.
- The Notice of Privacy Practices could not be read due to the emergent nature of the care of other reason
Please describe*
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
Date*
MM slash DD slash YYYY
Patient Name*
Signature*
Representative (if signing as a representative of the patient
Relationship
Disclosure of Medical Information Consent
I give permission to have any/and or all of my medical information, including financial, from NW Family Eye Care released to the following individuals listed below.
I agree
Authorized Representatives
Name Phone Number Relationship to Patient
Date*
MM slash DD slash YYYY
Signature*
Emergency Contact Information
Name*
First Last
Relationship to Patient*
Date*
MM slash DD slash YYYY

Medication	For what?

Name	Phone Number	Relationship to Patient

Patient Information

Social History

Medical History

Eye History

Review of Systems

Dilation Of The Pupils

Payment Policy

Acknowledgement of Notice of Privacy Practices

Disclosure of Medical Information Consent

Emergency Contact Information