Nethery-New-Reg-Form – LONG FORM – Nethery Eye Associates

Date*

Full Name*

Gender

Male

Female

Email Address

Mailing Address*

City*

Home Phone

State*

Work Phone

ZIP*

Cell Phone

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Unknown

Decline to Specify

Spouse Name

Work Phone

Cell Phone

Parent/Guardian

City

Home Phone

State

Work Phone

ZIP

Cell Phone

Nearest Relative

City

Home Phone

State

Work Phone

ZIP

Cell Phone

Referred by

Authorization

Patient Name

I hereby authorize my doctor to release to the Social Security Administration or other insurance carriers any medical or other information needed for all services that I receive. I request that all insurance payments be made directly to my doctor. I understand if my insurance does not pay within 45 days or decides the service is “non-covered” that a bill will be sent directly to me. I further understand that I am responsible for any deductibles, co-insurance, and refraction fees at the time of service.

I agree to the above statement or requirement*

Yes

I also understand that, if at any time, I change my insurance coverage to a managed care plan (i.e.Secure Horizons, Pacificare, or any other comparable plan) or change my primary physician, I amresponsible for notifying your office of such change. If I fail to obtain a valid referral prior to my visit and I decide to be seen by Nethery Eye Associates, I understand that my services will be considered out of network and I will be solely responsible for the fees incurred.

I agree to the above statement or requirement*

Yes

Digital Signature*

By clicking yes above and by entering your name here you agree to these terms.

Date

Patient Information

Patient Name*

Primary Care Physician

Optometrist Name

Date of Birth*

Physician's Phone Number

Pharmacy Name

Past Medical History - Please check the box and list the date of onset

Anxiety

Date of Onset

Hearing Loss

Date of Onset

Arthritis

Date of Onset

Hepatitis

Date of Onset

Asthma

Date of Onset

Hypertension

Date of Onset

Atrial Fib (Irregular Heart Beat)

Date of Onset

HIV/AIDS

Date of Onset

Bone Marrow Transplant

Date of Onset

Hypercholesterolemia

Date of Onset

BPH/Urinary Problems

Date of Onset

Infectious Disease

Date of Onset

Breast Cancer

Date of Onset

Leukemia

Date of Onset

Colon Cancer

Date of Onset

Liver Disease

Date of Onset

COPD/Emphysema

Date of Onset

Lung Disease

Date of Onset

Coronary Artery Disease

Date of Onset

Lymphoma

Date of Onset

Depression

Date of Onset

Prostate Cancer

Date of Onset

Diabetes Type I

Date of Onset

Radiation Therapy

Date of Onset

Diabetes Type II

Date of Onset

Seizures

Date of Onset

End Stage Renal Disease

Date of Onset

Stroke

Date of Onset

GERD

Date of Onset

Thyroid Disease (Hyper/Hypo)

Date of Onset

Please list any surgeries you have had:*

Please list any allergies:*

Ocular History

Have you been diagnosed with any eye condition/disease? If yes, please check the box and list the date of diagnosis.

Cataracts

Date of Onset

Macular Degeneration

Date of Onset

Dry Eyes

Date of Onset

Macular Degeneration

Date of Onset

Glaucoma

Date of Onset

Have you had any eye surgeries? If yes, please list type of surgery, date of surgery, and name of surgeon.*

Do you use eye drops?*

Yes

If yes, please list the name of eye drops you are currently using:

Are you currently taking any medications?*

Yes

If yes, please list medications:

Are you allergic to any medications?*

Yes

If yes, please list medications:

Have you ever smoked?*

Yes

When did you quit?

Do you drink alcohol?*

Yes

If yes, how many drinks do you have in a typical day?

If over age 65, how many times in the past year have you had 4 or more drinks in a typical day?

Current Occupation

If retired, please list previous occupation:

What are your hobbies/interests?

Do you have a family history of: (if yes, please list relation)

Diabetes*

Yes

Who

Stroke*

Yes

Who

Heart Attack*

Yes

Who

Glaucoma*

Yes

Who

Macular Degeneration *

Yes

Who

Notice of Privacy Practices - Review Acknowledgement

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

I agree to the above statement or requirement*

Yes

Digital Signature*

By clicking yes above and by entering your name here you agree to these terms.

Date

Name of Patient or Personal Representative*

If not patient, please describe Personal Representative’s authority

Please list the names of the persons you authorize Nethery Eye Associates to communicate with regarding your medical care:

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

By Submitting this form, you understand all the above statements.*

Yes

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