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 Information
Name*
Prefix First Last Suffix
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Reason for Visit?*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender*
- Female
- Male
Ethnicity*
Race*
Phone Number*
Please provide a telephone number, with area code, so we can contact you.
Daytime Phone*
Cell Phone*
Email Address*
Please provide us your email address.
Communication Preference*
Personal Information
Marital Status*
Marital Status - Other
Please provide your marital status.
Preferred Language*
Employment Status*
Employment Status - Other
Please provide your employment status.
Employer*
Occupation*
How were you referred to our office?*
Referral Status - Other*
Please let us know how you were referred to our office.
Eye History
Please check off any current conditions you suffer from*
- I stopped wearing glasses
- I stopped wearing contact lenses
- 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
- Mucous Discharge
- Drooping eyelid(s)
- Redness
- Sandy or Gritty Feeling
- Strabismus (crossed eye)
- Blurred Vision at Distance
- Blurred Vision at Near
- Haloes
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Vision
- Loss of Side Vision
I stopped wearing glasses because:*
I stopped wearing contact lenses because:*
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you own?*
- Single Vision
- Bifocals
- Safety Glasses
- Backup Glasses
- Progressive
- Trifocals
- Sports Glasses
- Sunglasses
- Other
Other glasses:*
Please tell us what other kinds of glasses you own.
How many hours a day do you use a computer?*
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.
Please check off any current conditions you suffer from*
- I am having problems with my current glasses
- There are times when I would rather not be wearing glasses
- I have problems with glare
- I have problems with night vision
- I am allergic to nickel (e.g. frames of glasses)
- I don’t have spare set of glasses
- My spare glasses have an incorrect prescription
- My sunglasses are missing UV (ultra-violet) protection
Contact Lens History
Do 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 off all that apply to you*
- 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 changing or enhancing my eye color
- I am interested in a non-surgical method of vision correction
- 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 History
When, 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?*
Do you smoke?*
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)*
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)*
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)*
Please list all hospital surgeries you have ever had:*
Please list all prescription and over-the-counter medications you take and for what conditions*
Please list all drug allergies you have*
Please check off any current conditions you suffer from*
- 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 Medical Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name*
Insurance Company Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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 Medical Insurance
Do you have secondary insurance?*
- Yes
- No
Insurance Company Name*
Insurance Company Phone Number*
Vision Insurance
Do you have Vision Insurance?
- Yes
- No
Name of Vision Insurance*
Pharmacy and PCP*
In case of a medical emergency, who should we contact?*
Contact Number*
If you have coverage through another plan/organization, please fill in the details below.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number*
Group Number*
Insured's Date of Birth*
MM slash DD slash YYYY
Patient's Relation to Insured*
Comments
If you have any comments you would like to add, please enter them here.*
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Please read and sign our Office Policies below:
HIPAA Privacy Policy
Haden Eye Center will maintain the privacy of your health information and personal data. Your information will only be released upon your authorization. The law permits us to disclose your information for treatment, payment, and regular health care operations. A detailed privacy statement can be provided upon request. Federal Law requires that you be made aware of your privacy rights regarding your personal medical information.
Financial Policies and Assignment of Benefits
Payments are due at the time of service. For our patients with insurance, our contracts with insurance companies require us to collect your co-pay at the time of service. Payment is also due at the time of service for any portion of your visit not covered by your insurance. We accept cash, check, and all major credit cards. If your personal check is returned due to non-sufficient funds, a returned check fee of $30.00 will be charged to your account. Payment for returned checks is payable only by cash, money order, or credit card. Collections Policy — All balances are due at the time of service on or before the statement due date. Balances not paid by the statement due date may be reported to Capital Accounts and documented on your credit report. All collection fees are your responsibility. Accounts sent to Capital Accounts become public record and will show that you received treatment in our office. We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays, or non-covered services as allowed by the insurance contract. Many patients have both medical and vision benefits. Vision Plans are designed to cover a prescription for glasses and help pay for lenses. It is not intended to cover medical conditions and treatments. Medical insurance applies to situations when a medical problem affects the eyes (such as diabetes, cataracts, and glaucoma, to name a few). When such conditions are being managed, we submit a claim to the medical insurance and co-pays, deductibles, and co-insurance will apply. Vision plans do not cover these issues. We are obligated to comply with the regulations set forth by insurance companies. Payment in full is expected at the time of order. All glasses and contacts must be picked up within 90 days of order placement. After this time all materials will be returned to stock and all deposits will be lost. Materials cannot be dispensed until paid in full.
CONTACT LENS FITTING AND EVALUATION POLICIES
There is an additional fee for obtaining a contact lens prescription that is separate from your comprehensive eye exam. The contact lens fitting fee is non-refundable and ranges in costs from $40-$70 depending on the complexity of the lenses that you wear. The contact lens fee covers evaluation of your current lenses or the initial fitting of a lens, as well as follow-up care within 3 months of the initial fitting. If you do not finalize your contact lens prescription within 3 months, you will be required to return for another contact lens fitting and will be charged another fitting fee. Professional fees for services rendered are non-refundable. I hereby authorize Haden Eye Center to: (1) release any information necessary to insurance carriers regarding my illness and treatment; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature or digital signature to be used in processing claims for the period of a lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from Haden Eye Center on behalf of myself and/or dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of treatment authorized. I further understand that fees are due and payable on the date services are rendered and agree to pay all such charges incurred in full upon presentation of statement. A photocopy or digital copy of this assignment is considered as valid as the original. By signing below, you are acknowledging that you have read and agree to all the above stated policies.
Signature*
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Name
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Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Medical Insurance

Secondary Medical Insurance

Vision Insurance

Comments

Privacy Policy

HIPAA Privacy Policy

Financial Policies and Assignment of Benefits

CONTACT LENS FITTING AND EVALUATION POLICIES