CHIZ27 Welcome NP Adults Form

Adult Patients - Demographic Form

Please complete the virtual registration. If you don’t, be prepared to spend extra time completing it in the office.

If the patient is new, how did you hear of us:

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Social Security Number

Patient's gender*

Preferred pronoun

Race

Language Preference

Address where patient lives*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Phone Number*

Please enter a valid phone number.

Home Phone Number

Please enter a valid phone number.

Email

example@example.com

Other Phone Number

Please enter a valid phone number.

Alternate phone is for:

Patient's workFamilyOther

Can we send/leave you reminders via (check all that apply)*

TextEmailVoicemailAll

Please attach a photo of the patient's government issued ID (driver’s license, passport or military ID, etc.). You can use your cell phone to take the picture.

Insurance Information

Please attach a photo of the FRONT side of the patient's PRIMARY insurance card. You can use your cell phone to take the picture.

Please attach a photo of the BACK side of the patient's PRIMARY insurance card. You can use your cell phone to take the picture.

Do you have secondary insurance?

YesNo

Please attach a photo of the FRONT side of the patient's SECONDARY insurance card. You can use your cell phone to take the picture.

Please attach a photo of the BACK side of the patient's SECONDARY insurance card. You can use your cell phone to take the picture.

Family and Other Eye Doctor's Information

Please list your family doctor, referring doctor and other eye doctors you have.

	Dr's Name	Type of Dr (Internist, Eye, Etc.)	Office Phone	Address
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2.
3.
4.

Pharmacy Information

Pharmacy Name*

Pharmacy Cross Streets*

AUTHORIZATION TO RELEASE HEALTH INFORMATION TO FAMILY/FRIENDS
To make it easier to discuss medical care about you with those that
help you with care, we ask that you complete this form.

It is NOT necessary for you to give us permission to provide medical information
to your other doctors. Example of who needs permission for us to
talk to would be spouses/partners, children, parents,
aunts/uncles, siblings, friends, neighbors, etc. I AUTHORIZE:

HIPAA Approved Contacts *

	Name	Phone	Relationship	Date of Birth
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I understand that Children’s Eye Care (CEC) does NOT participate with VISION insurance. Visits will be billed to the medical plan.

CEC may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to CEC for reimbursement for services rendered, and (2) any health care provider for continued patient care. CEC may also disclose on an anonymous basis any information concerning my case, which is necessary or appropriate for the advancement of medical science, medical education, medical research, for the collection of statistical data or pursuant to state or federal law, statue or regulation. A copy of this authorization may be used in place of the original. I authorize that my protected health information (also known as PHI) may be used or disclosed with the above-mentioned people. I understand that I have the right to be aware of all PHI that will be disclosed to these people. I understand that Children’s Eye Care will not condition any aspect of my treatment or payment I understand that I am under no obligation to sign this Authorization. I understand that this Authorization may be revoked in writing at any time by my signing the revocation section below and returning it to Children’s Eye Care unless: they have previously acted in reliance on this Authorization. By my signing the Authorization, I acknowledge that I have read and understand this Authorization. Further, I give my authorization to Children’s Eye Care to use or disclose PHI in accordance to the terms of the Authorization. Financial Agreement: I agree that in return for the services provided to the patient by CEC, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to CEC for payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to CEC. If copayments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to CEC. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill. Also, I agree to reimburse CEC the fees of any collection agency , which may be based on a percentage at a maximum of 25% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient's Signature*

Touchless/Virtual Payment

If you’d like to pay your copay virtually, please click on the link. It will open in a new window, but please come back and complete this form! Thank you! Payment Portal

How to make your exam easier and more efficient:

Bring all medical insurance cards and your driver’s license/ID. We do not participate with vision insurance so we don’t need that card for billing the exam. If your insurance company requires authorization or referral from your primary care doctor, please obtain this authorization for your first visit and for every visit thereafter.
If you already wears glasses, please bring them with you. Also, please note that we won’t be assessing glasses prescription needs (that’s done by your regular eye doctor). The only thing we assess about glasses is if prisms are needed to help control double-vision issues.
Be prepared to pay for any services not covered (copays, deductibles, etc) by your insurance company using cash, check or credit card.

Things to know:

We have a lot of educational info and videos about adult strabismus/diplopia eye exams on Children’s Eye Care’s website.

	Yes	No
Have you recently had a fever?
Have you recently had unintentional weight loss?
Do you smoke cigarettes (including vaping)?
Do you use recreational drugs?
Do you abuse alcohol?

	Check all that apply
notice it when looking at far distances (driving, watching TV, playing sports, etc.)?
notice it when looking at near ranges (reading, using computer, doing fine handiwork like knitting, etc.)?
notice it when look a far and near ranges?
close your eyes for comfort?

	Yes	No	Details
If you get double vision, do you have prism(s) in your glasses?
Do you ahve distorted vision? If yes, which eye?
Do you have eye strain?
Do you have misaligned eyes but no double vision?
Did you have eye misalignment in childhood?
Have you previously had eye muscle surgery? If yes, please be certain to document surgery in "Previous Eye Surgery" area below.

	Yes	No
Lazy eye/amblyopia (since childhood)
Corneal disease
Diabetic eye disease
Glaucoma
Retinal detachment/disease

	Yes	No
Lazy eye/amblyopia (since childhood)
Corneal disease
Diabetic eye disease
Glaucoma
Retinal disease

	Yes	No
Cancer
Diabetes - adult onset
Diabetes - childhood onset
Graves/Thyroid disease
Heart disease
High blood pressure
HIV/AIDS
Problems with anesthesia
Malignant hyperthermia
To take antibiotics prior to dental work or surgery?
Kidney disease
Lung breathing disease
Lupus or Multiple Sclerosis
Psychiatric disorder
Parkinson's disease
Renal failure
Rheumatoid failure
Rheumatoid arthritis
Skin disease
Sleep apnea and use of CPAP

	Medication Name	Dosage	Use (if known)	Reason Taking Med
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