Vantage Eye Center
Patient Registration Form

Print form, fill out and mail or bring with you. Addresses at contact page.

Personal Information

PATIENT NAME:______________________________________________________________DOB: _________________________
First
Middle Int.
Last
Month
Day
Year

SOCIAL SECURITY NUMBER: _______-______-________________

 SEX: M F Age:__________

MAILING ADDRESS : ______________________________________
CITY ____________________STATE: ___ ZIP: ______________

WORK / MESSAGE: (_______)_________________________

EMPLOYER: _______________________________ OCCUPATION: ________________________________________

EMPLOYER ADDRESS: _________________________________________

 EMPLOYER PHONE: (_______)________________
REFERRED BY DR._____________________________________________
FAMILY PHYSICIAN: ___________________________________________

EMERGENCY CONTACT: _______________________________________

 RELATIONSHIP___________________________

PHONE: (_______)__________________

Insurance Information:

PRIMARY INSURANCE:_________________________________

 ID/SS#:_____________________________

SUBSCRIBER NAME: _________________________________

 RELATIONSHIP TO PATIENT:_______________
SUBSCRIBER EMPLOYER:_________________________________ SUBSCRIBER DOB:_____________

SECONDARY INSURANCE_________________________________

 ID/SS#:___________________________

SUBSCRIBER NAME:_________________________________

 RELATIONSHIP TO PATIENT:____________
SUBSCRIBER EMPLOYER:_________________________________ SUBSCRIBER DOB:____________________
COMPLETE IF PATIENT IS LESS THAN 18 YEARS OR A FULL-TIME STUDENT:

FATHER'S NAME: _________________________________

 DAY-TIME PHONE: (_______)_____________

MOTHER'S NAME:_________________________________

 DAY-TIME PHONE: (_______)_____________

Financial Assignment and Insurance Authorization:

I AUTHORIZE PAYMENT OF INSURANCE BENEFITS TO VANTAGE EYE CENTER FOR PROFESSIONAL SERVICES RENDERED. I AUTHORIZE RELEASE OF ANY OR ALL INFORMATION NECESSARY TO PROCESS MY INSURANCE CLAIM. THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO PAY FOR ALL CO-PAYMENTS, CO-INSURANCE, DEDUCTIBLES, AND ANY SERVICES NOT COVERED BY MY INSURANCE AT THE TIME OF SERVICE. I AM AWARE THAT ALL ACCOUNT BALANCES OVER 60 DAYS MAY INCUR A MONTHLY FINANCE CHARGE OF 1.5% (18% APR).

SIGNATURE: __________________________________________________________________

Medical History Form

LIST any medical conditions that you have (e.g., diabetes, high blood pressure, arthritis, etc.):

LIST any eye conditions that you have (e.g., glaucoma, cataract, wandering or "lazy" eye, retinal detachment):

LIST any medications that you take:

LIST any drug allergies:

Do you have any of the following problems:
If yes, please explain

Chronic fever, unexpected weight gain/loss, fatigue

YES NO

Ear/nose/throat problems (e.g., hearing loss, sinus problems)

YES NO

Heart Problems (e.g., chest pain, irregular heartbeat)

 YES NO

Respiratory problems (e.g., shortness of breath, wheezing, asthma, bronchitis)

 YES NO

Gastrointestinal problems (e.g., heartburn, diarrhea, abdominal pain)

 YES NO
Urinary problems (e.g., pain or discomfort, bladder infections) YES NO
Skin disease (e.g., rashes, eczema, dermatitis) YES NO
Musculoskeletal problems (e.g., muscle aches, arthritis, swollen joints) YES NO
Neurologic problems (e.g., numbness, weakness, paralysis, headache) YES NO

Psychiatric problems (e.g., depression, anxiety)

 YES NO
CHOOSE any of the following eye conditions that run in your family:
glaucoma macular degeneration retinal detachment
DO YOU: * Smoke? YES NO How much? _________________
Drink Alcohol? YES NO How much? _____________________

*Reviewed by Physician Comments:

Physician Signature: ____________________________
Date: ________________