Patient Registration Form Name First Last Birthdate MM slash DD slash YYYY Age Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmployer/School Primary Care Physician Approximate Date of Last Eye Exam lnsurance lnformationMember's Name First Last Member's DOB MM slash DD slash YYYY Member's SS # Patient's SS # Employer Please read and sign below: I authorize Nicole Whitaker OD to act as my agent in helping to obtain payment from my insurance company. I authorize payment directly to my doctor, and I permit this form to be used as my "Signature on File" for all my insurance submissions. I authorize release of any information needed to obtain payment to my doctor. I understand that I am responsible for payments to Nicole Whitaker OD, regardless of my insurance coverage. I understand that in the event my insurance company denies payment, I am responsible for the balance in full. I am aware that I am responsible for any copayments and/or yearly deductible as specified under my insurance contract. Exam fees and copays are non-refundable.Patient or Parent/Guardian SignatureComplaint/Reason for visit Have you ever been diagnosed with the following conditions? Cataract Eye infection, inflammation, allergy Age Related Macular Degeneration Floaters/Flashes of light Glaucoma lritis/Uveitis Diabetes Retinal Defects Diabetic Retinopathy Dry Eye Previous Eye Surgery Other If other, please specify: Current Eye Concerns? Redness Burning Itching Tearing Discharge Eye Pain Other If other, please specify: Current Vision Concerns? Blur Eye Strain Light Sensitivity Headache Night Vision Double Vision Vision Loss Other If other, please specify: Current Vision Correction:Do you wear: Glasses Contacts Both Are you experiencing problems with... Distance Vision Near Vision Computer Vision Review of Systems:Please check if applies and elaborate if possible. Hypertension Cancer Thyroid Disorder Stroke High Cholesterol Arthritis Heart Disease Diabetes Acid Reflux Neurological Disorder Sinus Problems Psychiatric Disorder Other/Ellaborate:Current Medications: Medication Allergies: Environmental Allergies: Seasonal Dust Mold Pets Latex Other If other, please specify: Tobacco Use: Yes No Formerly Alcohol Use: Yes No Formerly Family History: Diabetes Cataracts Heart Disease Hypertension Macular Degeneration Thyroid Disease Cancer Other If you checked any of the conditions above, please specify the condition and indicate relationship:ConditionRelationship *Please Note: Payment for examination and 1/3 of materials charge is due today. The balance is due on the date of dispensing. You may have a copy of your refractive prescription on completion and payment of our services. Thank you very much for your kind cooperation.